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.

• 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.

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.

The post Phantom Brain Pain – “The Doctor is Missing Something” first appeared on Back in Control.

The post Phantom Brain Pain – “The Doctor is Missing Something” appeared first on Back in Control.

• Although there is no question about the dedication of physicians to providing excellent care, the rigors of training, the demands of practice, and the business of medicine have made it increasingly difficult to treat you – a person.
• A major factor is doctors are not allowed the time it takes to talk to you and understand the full nature of your problems. Major decisions are made based on inadequate data.
• Spine surgery is one of the bigger problems because the downside of a failed spine operation can destroy your life.
• An even larger issue is that once you have failed a surgical procedure, who is going to take care of you and the fallout of the procedure? Almost no one.
• You are essentially thrown onto a scrap heap. Much of my surgical practice involved pulling patients out of this pile. But the successes I witnessed were from the patients climbing out of The Abyss on their own with guidance – not from more surgery.
• Please do not allow yourself to become part of this mess and if you are already in it, become keenly aware of how to pull yourself out.

Physicians’ commitment to excellence borders on heroic. They undergo many years of training, endure long hours, continue to learn, and just plain work hard. Modern medicine with its technology allows doctors to deliver high-level services for a wide-range of challenging situations. The ability to deliver most of these specialized interventions comes from prolonged repetition, similar to any high-level performer. I spent 15 years in training after I completed high school, and the minimum for any physician is 11 years. Doctors give up their twenties in order to learn the skills required to deliver quality care. Why do we do it?

Originally, it begins with a deep desire to help others. A paper out of Philadelphia measured the level of compassion of college students applying for medical school, and it was significantly higher than the national average. However, it plummeted during the third year of medical school. (1) The reasons are clear. Many training programs require long hours, compliments are few and far between, and the mindset is often, “If you can’t take the heat, get out of the kitchen.”

Where did the patient/ physician relationship go?

This study didn’t even look at the rigors of residency and fellowship, which makes medical school seem like a tropical vacation. The stress becomes even more intense in practice. Doctors are now on the front lines with little backup, and the business of medicine is demanding that they are productive.

There are many consequences of this for you, the patient. The largest one is that doctors are not allowed to talk to their patients without significant financial consequences, and sometimes punitive actions are taken. Physicians are increasingly on an “assembly line,” and burnout is skyrocketing, rising well above 50% depending on the study. (2) Ironically, in the midst of all of this chaos, the one factor that prevents and helps burnout is their patients – if they can sneak in the time to talk to you. The patient-physician relationship is the essence of healing – for all parties.

The most dangerous aspect of this situation is that doctors don’t know the full story behind your symptoms – and you don’t feel heard. No situation in any arena of life can be effectively assessed and addressed without knowing the details. This is particularly true in medicine. Stress creates changes in your body’s chemistry, and it translates into many different physical symptoms. The end result is that simplistic solutions are quickly prescribed for complex problems. Anything that remotely appears complicated is usually met with a referral or dismissal.

One common example is patients will come in with prescriptions for ten different medications, sometimes many more. The potential drug interactions alone creates its own universe of problems. It takes time to sort through what the best combination might be, and it is much faster to prescribe another drug.

The end result of this current environment is that few physicians have the training or capacity to take care of you – the whole person. The rise of integrative medicine is promising but isn’t going to effectively solve your problem today.

The business of modern medicine has forgotten its foundational mission – to take care of you – all of you.

Spine surgery

This scenario is especially problematic in spine surgery. Spine surgery is often the most profitable service in the hospital system and every effort is made to increase productivity. “Productivity” is demonstrated in the form of more surgeries – whether they are effective or not. The most glaring example of this is surgeons performing fusions for lower back pain. The success rate at two-year follow up is less than 30%, and there is a significant chance of making you worse. (3,4) If you are a patient who had a successful outcome, consider yourself fortunate. That is not the case with most people.

The reason I took the time to explain the above scenario is because that isn’t the end, or even the worst part of this story. Once the post-op care is done, patients are usually discharged from the surgeon’s ongoing care, whether they are doing well or not. Surgeons feel like they did the best that they could, but their part is now done. Physicians are not only supposed to be productive (i.e., profitable), but have no incentive or encouragement to care for patients if the operation fails. Then what?

FBSS

One option is that you might be referred to a pain specialist, and there are not nearly enough of them. In our current medical culture, another surgeon isn’t going to care for another surgeon’s failure. Maybe you were sent to a psychologist, but chronic pain is not primarily a psychological issue. The rehab physicians can work on mechanics. The group that is best equipped to care for you is your primary care doctor and they are often overwhelmed – and also not given the time to talk to you. There is nowhere for you to go. You have literally been dumped onto the scrapheap of failed backs. There is even a name for your condition – “Failed Back Surgery Syndrome” (FBSS). This is a rapidly growing group, as we are continuing to efficiently perform ineffective operations.

Your life devolves into fighting for pain meds, embarking on an endless quest for answers, convincing the world that you really are in pain, and so on. Now you really are trapped, your body chemistry is way off, and your family is also suffering the consequences. These letters are representative of scenarios I see every week.

Pennsylvania failure

My mom had back surgery 15 years ago by a prominent spine surgeon in Pennsylvania. He ended up damaging a nerve, and sadly she has suffered greatly all of these years. She has pain from her lower back down to her one foot. Nothing could be done. She walks with a limp and needs Lyrica just to have some pain relief. She says over and over, “I wish I NEVER had this damn surgery.”

This should not be happening to people who just want pain relief and trust their doctor’s judgment fully. This physician is still practicing in Pennsylvania, which is so upsetting. He never claimed any responsibility for this terrible outcome.

 A parent’s plea

My 28 year-old daughter was in a car accident five years ago. Three years ago, she had a fusion in hopes she could stop suffering from horrible back pain. Now, she’s worse. Her back surgeon is dismissive/offers no help.  

Now my daughter is seeing a neurosurgeon who may suggest another operation (after studying her myelograms & doing a pain block in the area that appears to be impinging on her nerves).  Meanwhile, my daughter, one of the most personable & dynamic people you could ever meet, has become antisocial, angry, anxious, etc. and the collateral damage to our family is extreme.

How can we help her become whole & happy again?  She is more than willing to go somewhere for a period of time to get the tools to live a happy & fulfilling life.  Can you suggest anything?  Are there such resources?  I hope you can help!

Please don’t join this club

Over half of my practice was working on providing an overall plan of care for patients who had prior spine surgery that had failed. It is not that difficult to create the structure needed to get people back on track. Patients are smart and resilient, if given even a glimpse of a solution. This is how The DOC Journey evolved. Patients organize their own set of resources to move back into a normal life and often thrive.

This is the reason why I quit my spine surgery practice and it is still getting dramatically worse. Even larger documented ineffective procedures are being performed that have a high incidence of complications. I am committed to doing what I can to prevent and solve this problem of “hit and run” surgery.

You, the patient, may have gotten got hit and it is more profitable for the medical system to have you hauled off to the junkyard than to salvage you. My book, Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice, is one of my efforts to prevent you and your family from joining the FBSS club.

Recap

A basic factor in any successful endeavor is understanding the relevant issues that are affecting the situation. The combination of chronic pain being a complex problem and you being unique makes it particularly critical. It is not possible to make a good decision about your care without being listened to and heard. That is not happening often enough in the context of modern medicine becoming industrialized. None of this is going to change anytime soon.

You have to take on responsibility for your care. It is not a simple task but more doable than you might think. The DOC Journey provides a foundational set of knowledge and skills and allows other intervention to be more effective.

Do You Really Need Spine Surgery? Take Control with a Surgeon’s advice, breaks the decision to have spine surgery into two variables – your anatomy and the state of your nervous system. There are four categories of choices, and your decision will become clearer. One of my intentions of this book was to make surgeons more accountable to their patients and primary providers.

Hopefully, you can prevent yourself from having a failed spine surgery and then not being able to find the help you need. The system is not set up to care for the complexity of a “Failed Back Surgery Syndrome.” If you are already a member, you can still find your way out and a reason for you to consider embarking on The DOC Journey or a similar program. I was one of those who found my way out and the next lesson is my story.

References:

1. Mohammadreza H, et al. The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School. Acad Med (2009); 84:1182–1191.
2. Bundy, C. Physician Burnout and Distress: Is the Health Care System Impaired? Washington Medical Commission Newsletter (Winter 2018); pp. 1-2.
3. Carragee E, et al. “A gold standard evaluation of the ‘discogenic pain’ diagnosis as determined by provocative discography.” Spine (2006); 31:2115-2123.
4. Franklin GM, et al. “Outcome of lumbar fusion in Washington State Workers’ Compensation.” Spine (1994); 19:1897–903.

The post Stay Out of the Surgical Scrap Heap first appeared on Back in Control.

The post Stay Out of the Surgical Scrap Heap appeared first on Back in Control.

Maybe not

In spite of my advice to proceed with surgery, some patients, even with significant pain from a distinct identifiable problem, wanted to wait and try the non-operative structured care first. Many would return for what I thought would be the visit to make a final surgical decision and their pain would be minimal or gone. We never did the operation because the pain had resolved. The idea that calming the nervous system could diminish pain arising from a structural problem was a major shift in my thinking. I now have over 100 patients with surgical problems cancel surgery because the pain disappeared. The DOC process has significantly impacted my surgical practice.

Then I ran across several papers that pointed out that if you perform surgery in face of untreated chronic pain, that you can induce pain at the new surgical site up to 50% of the time (pain lasting for up to a year) and 5-10% of the time it was permanent. (1) In other words, if you had a hernia repair while suffering from chronic neck pain, the hernia site could become chronically painful. It’s usually an almost painless procedure. The chronic pain areas of the brain are already on overdrive and you’re now plugging in different body parts. It explained many of the surgical failures I have witnessed over the years in spite of a technically well-performed procedure.

More predictable outcomes

It then became clear that the patients who actively engaged in learning about pain and using the tools of the DOC project had much less pain post op, ambulated more quickly, and predictably would have a better outcome. Around 2013 our team agreed that we would only perform surgery on a patient who was willing to calm down his or her nervous system for at least eight weeks before elective surgery. Some patients simply didn’t want to have any part of taking charge of their own care and went elsewhere. The patients who committed to themselves predictably did well.

Ron

I first met Ron a few years ago. He was in his late 50’s and just plain angry. At the first mention of doing some reading about pain he exploded. He wasn’t going to have anything to do with it. I hung in there and explained that he was certainly welcome to have someone else perform the two-level laminectomy and one-level fusion in his lower back. But it would not be me. I was certain he wouldn’t be returning.

He did return and over the next three months he underwent a remarkable transformation with much less LBP and improvement in his mood. As his leg pain persisted, he underwent the surgery – and went home on the second post-op day almost pain free. He is muscular, and it was a significant operation. The normal time in the hospital is four or five days.

“I got to know you”

I was talking to him at his discharge and reminiscing about the first couple of times I had met him. I said, “I think that your engagement in structured care concepts was really helpful and I am impressed at your enthusiasm at embracing them.” He agreed that it was the correct choice to wait. Suddenly he stopped the conversation, looked at me and said, “I got to know you.”

There’s a lot of pressure to “be productive” in medicine. There are endless conversations about how to maximize the surgical yield of the clinic. Often surgeons require updated scans to be done before they will even see the patient. If there is a problem that is amenable to surgery, then the decision to proceed is frequently made on the first visit.

With few exceptions I will no longer make a surgical decision on the initial visit. Why? It is critical to know the context in which the decision is being made. What kind of stress are you under? Is your pain severe enough to undergo any procedure? Do you really know the risks? We don’t even know each other, and we are about to become partners in a risky venture.

Impact of stress

Some of the insights that have surfaced on the second or third visit are:

• “My son just died two months ago in a car accident.”
• “My husband retired, and we are driving each other crazy.”
• “I lost my daughter to breast cancer last week.”
• “I have a drinking problem.”
• “I lost my job”

These severe stressors impact both the perception of pain and also the decision-making process.  Do you feel comfortable discussing these details with a doctor you have just met? It’s a bad idea to make major decisions when your life has been impacted to this degree.

Wait!!

Knowing my patients allows me to teach them strategies that enable them to both decrease pain and cope with stress. Spine surgery is a significant stress. I also enjoy them.

Don’t make a major decision about surgery on your first visit. Would you buy a house or used car without an inspection? Why would you allow someone (including me) you have heard “has a great reputation” decide your fate in under an hour? The risks of spine surgery are too high and the potential downside can be catastrophic.

Know your surgeon – well and well before surgery. More importantly, make sure he or she knows you.

Listen to the Back in Control Radio podcast “he Healing Power of the Doctor-Patient Relationship.”

1. Ballantyne J, et al. Chronic pain after surgery or injury. IASP (2011); 19: 1-5.

Video: “Get it Right the First Time”

Are You Kidding Me?

The post Know Your Surgeon – Well first appeared on Back in Control.

The post Know Your Surgeon – Well appeared first on Back in Control.

Spine Surgery

Spine surgery is especially problematic because every procedure creates some degree of permanent damage to the spine. I have been on a 10-year search, but still have yet to find a paper that documents the effectiveness of a spine fusion for back pain compared to solid non-operative care. Yet, it is a multi-billion dollar a year source of revenue for health care systems, and spine surgery is often the service line that is the most profitable for the hospital. Procedures are aggressively marketed and surgeons are encouraged to perform interventions that don’t work. “Mainstream” medicine is currently pretending to practice medicine. In addition to the expense and risks involved, it has been shown in primate studies that an effective way to induce depression is to repeatedly dash hopes. (8)

“Breaking up is hard to do”

Breaking up with someone is a painful experience and often elicits strong emotions. Yet, it’s been shown that most people recover from a breakup much faster than they thought and eventually feel better. The opposite occurs when a parent breaks a promise. Almost all of us remember looking forward to going to a big event with our parent, and then having it cancelled at the last minute. Dashed hopes are painful, and the hurt feelings might persist. Repeated broken promises will eventually take a toll on the relationship. It’s better not to make a promise that you weren’t really intending to follow through on or had a low chance of pulling off.

Dashed hopes

I’ll never forget an elderly patient who I had been following during my first year of internal medicine training. We had been adjusting his medications for his lung problems, and he had been doing well. In mid-December he was admitted for respiratory failure. I was stunned and upset when he died 3 days later for no apparent reason. It turned out that his son had not invited him home for the traditional family gathering at Christmas.

Possibly, the most straight-forward orthopedic surgery we perform is a total hip or knee replacement. They usually work well, but not as predictably as you might think. If you’ve had a great outcome with your joint replacement, there is nothing like it and you can’t believe you waited to have it done. However, a significant percent of people have a sub-optimal outcome that includes ongoing pain, stiffness, fractures around the prosthesis, dislocations, loosening, infections, blood clots and death. If you weren’t prepared for these possibilities, then the situation is even worse when one of these problems occurs. No one thinks that they will be the one to have a complication. It needs to be clearly factored into any surgical decision-making.

Would you undergo a spine fusion for back pain if you knew the long-term success was less than 30% and there was a 15% chance of needing a second operation for a complication within the first year? (9) What about having your pain become significantly worse after a well-performed surgery?

What are your expectations?

I had a patient who I had spent several months working on his sleep, stress, medications, etc. before I did his surgery. He wasn’t really buying into any of this chronic pain stuff, and I was extremely clear that I was doing the operation only for his extreme bilateral leg pain. His nerves were pinched so tightly that I felt compelled to move forward without his full engagement in his own healing process. I thought we had a reasonable working relationship. The surgery went well, and he had complete relief of his severe leg pain. He came in for his routine follow up and verbally took my head off. I was excited about the outcome, but he was angry beyond words that his back still hurt. “You screwed me up.” He was livid. He didn’t remember the multiple times I had tried to set realistic expectations about the goals of surgery. I felt bad that I somehow wasn’t able to communicate the expected outcome to him.

Understand pain

Make no mistake about it. Pain is only pain when your brain tells you that a given stimulus is uncomfortable. Your range of responses may range from shifting a little bit in your chair to jumping up and running as fast as you can. Your pain system is elegant and allows you to act in a manner that keeps you safe. The same pain impulse might feel minimal on a day that you are engaged in meaningful activities or intolerable if you are already upset and not sleeping well. One paper demonstrated that just one night of sleep deprivation significantly lowered the pain threshold in volunteers. (10)

Dr. Lorimer Moseley is a leading neuroscientist from Australia who I have enjoyed getting to know. Not only is his work brilliant, he presents his findings in an understandable way. He is passionate about getting the basics of the neuroscience of pain into the public domain and founded the “Pain Revolution” in his country. His vision and commitment are remarkable. This video is an excellent overview of the nature of pain. He and I differ in one obvious way in that I make many attempts at humor, and he’s actually entertaining. You’ll enjoy his TEDx talk below.

Lorimer Moseley – Why Things Hurt

It doesn’t matter from where the pain originates. Most pain initially arises from the soft tissues, and it’s often severe because there are over a million pain receptors in each square inch of the soft tissues. Some of the worst and persistent pains I have experienced are from tennis elbow, achilles tendonitis and plantar fasciitis. Yet there isn’t a test that would identify the exact cause of the pain. The presence of a bone spur doesn’t necessarily mean it’s the source of pain. In fact, it has been clearly shown that disc degeneration, herniated discs, ruptured discs and spinal arthritis are NOT sources of neck, thoracic or low back pain.

There is a trend in medicine to focus on anatomy and treat pain from a perspective of finding the source and fixing it. It is a similar approach to taking your car into the shop for repairs. However, machines don’t have a nervous system. They are dead. There isn’t an interpretive pain function. It is well-documented that chronic pain is a “maladaptive neurological disorder” (11) and therefore wouldn’t be expected to be affected by most structurally-oriented procedures.

Phantom limb pain is one of the more dramatic illustrations of the neurological nature of chronic pain, and it occurs in over half of people undergoing amputations. The source of the pain is obvious with the affected limb being compromised by trauma or lack of a blood supply. There isn’t a more definitive surgery than completely removing the offending limb. Yet the pain may not change – at all. This can occur in any part of the body when the pain is present for more than 6 – 12 months. (12)

Setting expectations

I’ve learned that it’s critical to set concise expectations before making a shared decision about what to expect from a given procedure. I perform a lot of spine surgery for pinched nerves with corresponding arm or leg pain (radicular pain). I’m clear that spine surgery isn’t effective for neck, thoracic or low back pain (axial pain). There may be some relief for 12 to 18 months, but by two years from surgery, the pain in these areas is the same for most people. It is also important to communicate and understand why the surgery is being done. If axial pain is the main concern, then surgery should be avoided. If the surgery is for the arm or leg pain, many patients assume that the axial pain will disappear. It doesn’t, and if it does, count yourself fortunate.

Why am I writing this post? The bigger problem is the dashed hopes. If your expectation is that both your axial and radicular pain will be relieved, you’ll be upset when that doesn’t happen. And when you’re upset, your body’s level of stress chemicals will increase, and the pain can often become even worse. I used to think that relieving the radicular pain would make a person happy enough that it wouldn’t make much difference in the outcome. Wrong!! One my fellows succinctly pointed out that whatever pain that’s left is now 100% of the pain. It took me a couple of decades to figure this out.

Dashed hopes in any realm are a problem, especially with regards to your own health. It is becoming a bigger problem in that doctors are not being given the time to get to know their patients and establish effective lines of communication. If you don’t feel like you’re being heard, or you aren’t being given understandable explanations, then be persistent or move on to another surgeon. If a surgeon doesn’t like being challenged, then run. It’s his or her basic responsibility to communicate with you. Failed spine surgery is especially problematic in that the results can be catastrophic and destroy any semblance of an enjoyable life. Get it right the first time!

Do You Really Need Spine Surgery? by David Hanscom, MD

1. Veehof MM, OskamMJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain. Pain. 2011;152(3): 533-542.
2. Cherkin DC, et al. Effect of mindfulness-based stress reduction vs. cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain. JAMA. 2016;315(12):1240-1249. doi:10.1001/jama.2016.2323
3. Baikie K, et al. “Emotional and physical health benefits of expressive writing.” Advances in Psychiatric Treatment (2005); 11: 338-346.
4. Baliki MN, et al. “Nociception, pain, negative moods and behavior selection.” Neuron (2015); 87: 474-490.
5. Hossain J, and CM Shapiro. “The Prevalence, Cost Implications, and Management of Sleep Disorders: An Overview.” Sleep and Breathing (2002); 6: 85-102.
6. Hanscom D, Brox I, Bunnage, R. Defining the role of cognitive behavioral therapy in treating chronic low back pain: an overview. Global Spine Jrn. (2015); http://dx.doi.org/10.1055/s-0035-1567836.
7. Peabody FW. The care of the patient. NEJM (1927); 88: 887-882.
8. Blum D. Love at Goon Park. Perseus Publishing, Cambridge, MA, 2002.
9. Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 1904
10. Krause AJ, et al. The pain of sleep loss: A brain characterization in humans.J. Neurosci 2019; 10.1523/JNEUROSCI.2408-18.2018
11. Baliki MN and A Vania Apkarian. “Nociception, pain, negative moods, and behavior selection.” Neuron (2015); 87: 474-491.
12. 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 Dashed Hopes first appeared on Back in Control.

The post Dashed Hopes appeared first on Back in Control.

The letter

Dr. Hanscom,

I have been meaning to reach out to you for some time. First, congratulations on your new endeavor and I’m excited to see and hear what you achieve. Second, I want to extend my gratitude for providing new, refreshing and empowering information.

I first heard you on the Pain Reframed Podcast with Jeff Moore and Tim Flynn. Your story, and the information you provided helped change my practice as a physical therapist.

At the time, I was working with a patient who was very focused on the pain she was having in her neck and some intermittent tingling in the left forearm. Midway through our time together, she had an MRI which showed degeneration, and disc bulging. Of course, her symptoms increased after reading the imaging report. I relayed that this was normal for her age (75 years old) and we went through a lot of effort to de-educate her and give her some hope.

She followed up with an orthopedic spine surgeon who recommended a five-level cervical fusion. At the time, she was convinced that she needed to have the surgery because her doctor said so. Her strength was excellent. Her reflexes were intact and equal bilaterally in the upper and lower extremities. I went through extensive phone conversations, face to face discussions that ultimately ended in frustration. She also has a son and she is his primary caregiver. The surgery would significantly impact his life as she recovered…I was at a loss…

Then, I tuned in for my weekly listen to Jeff and Tim’s podcast. When you walked through your 5-step process, I immediately started taking notes. I put together a print out for her and we discussed each step one by one. We went through each step over the course of about one month. She would periodically call me with questions and we would talk through any issues she was having implementing each step. One day she called, and her tone sounded different. Her surgery was scheduled for the following week, so I wasn’t sure what to expect. She said “Steven…I decided to cancel my surgery.” I was at a loss for words. She started to notice improvements in her symptoms and her ability to control her body’s response to different stimuli. We keep in touch and she still reaches out with questions and to get more information on how to improve her wellness.

I want to thank you for putting your message out there! I want to thank you for helping people that you have never met! I want to thank you for helping me and a patient who were at loss!

Without your willingness to change your practice and seek ways to serve your patients better, she would’ve had the surgery and who knows where she would be now. I’m sure you’ve done the same for many people, but I truly hope hearing these stories never gets old for you.

Thank you and keep spreading your message!

My thoughts

I am always inspired to keep moving forward when I hear stories like hers. I’m grateful that I have been able to give back in a way that’s consistently effective. We hear stories like this every week in and out of our clinic. At the same time, I am disturbed that my profession would remotely consider a five-level fusion as a reasonable option. It’s a big operation with a significant chance of complications such as trouble swallowing, having food go into her lungs, and vocal cord problems. I can quickly think of eight cases of one and two-level neck fusions that died after the operation. Additionally, not only is there a low chance of improving her pain, there is at least a 40% chance of making her worse. (1)

This story could have been written under the “Are You Kidding Me?” post. None of it is rational. I’m happy that somehow, she was able to not only halt the procedure, but she has largely recovered with minimal interventions and no risk or cost.

Video: Get it right the first time

Busted

I also heard a story from one of my fellows that caught my attention. Neurosurgery recently adopted a new format for the credentialing board exam, which is an oral examination based on cases performed during the first two years of practice. This process has been a step in orthopedic credentialing for a while. He had performed a fusion on a degenerated disc for low back pain. There is no good data to support the procedure. When the examiner asked him the reason for performing the operation, he was stuck. He blurted out that if he had known that he was going to have to take oral boards, he would have never performed the surgery. Who knows how many other questionable surgeries he had done with this mindset.

Please take full responsibility for making the decision to undergo any surgery. The medical culture in all arenas has veered towards procedures that have been documented to be ineffective. Dr. Ian Harris out of Australia has written a book, Surgery, The Ultimate Placebo: A Surgeon Cuts Through the Evidence, where he has documented the lack of data supporting multiple procedures and it hasn’t slowed anyone down from performing them.

I understand the desperate need for a solution for your endless pain without a shred of hope. It’s almost impossible to resist a surgeon walking in the room and saying with confidence that he or she can take care of your pain. Neuroscience research, in addition to well-documented effective treatments, has given us the answer to chronic pain. It’s a bit perplexing why this information hasn’t penetrated into mainstream medical care.

1. Ballantyne J, et al. “Chronic pain after surgery or injury.” Pain: Clinical Updates. IASP (2011); 19: 1-5.

The post Avoids a Five-level Neck Fusion first appeared on Back in Control.

The post Avoids a Five-level Neck Fusion appeared first on Back in Control.

He hadn’t worked for many years and was overtly angry at the employer, his family, me and generally the world. He was’t in any state of mind to read a book or engage in any of the tools to calm himself down. I still worked with him for 3 months to at least stop smoking and understand some of the basic chronic pain concepts. His stenosis was so tight that I thought we should still proceed with surgery.

He got worse

I have felt that when a severe surgical problem is solved that the amount of pain relief provided would allow my patients to function enough to move forward regardless of the patient’s state of mind. I surgically removed the constriction around his nerves and fused him at L3-4. The operation went extremely well and his nerves were completely freed. He got worse – a lot worse. Although I am always clear that LBP does not improve with surgery, I was sure that his legs would improve. They didn’t. It was my first hint that chronic pain was more complicated than I thought. I worked with him for almost a year trying to rehab him and finally had to let go.

“Just fix it”

Spine surgery should be performed only for an identifiable anatomic abnormality that is causing matching symptoms. For example, if your 5^th lumbar nerve root is being compressed by a bone spur then the pain would travel down the side of your thigh and calf. If the pain is located in a different area, then it would not be considered a structural problem. Surgery performed for a specific lesion generally yields a predictably satisfactory outcome. With this concept in mind, I have historically recommended that if you are suffering from chronic pain and now have an additional structural problem, you should have your operation performed more quickly since your nervous system cannot tolerate the additional insult.

I noticed that the results of my surgeries on clear-cut problems in the presence of long-standing pain weren’t consistent and patients would often be made worse. I had thought that the pain relief afforded by my surgery would compel people to move forward with the rest of their rehab. The severity of the pathology I was correcting was stunning. Ernie’s story is common. One of my fellows succinctly pointed out that whatever pain that is left is now 100% of the pain.

Chronic pain can be a complication of any surgery

I ran across a series of papers that showed that if you underwent a simple uncomplicated procedure, such as a hernia repair, while experiencing chronic pain in another part of your body you could end up in chronic pain at the surgical site up to 40% of the time. (1) Five to ten percent of the time it would become permanent. I was never taught that this was a possibility and it is not usually presented as a potential complication of surgery. If I had an infection rate of 5 – 10%, I would not be in practice for long – and infections are solvable. When will the pain stop?

A different driver

Another paper demonstrated that acute LBP is sensed in a specific pain center in the brain. It is well-known and easily identifiable. However, if you experience LBP for more than a year it switches completely over to the emotional center and the pain center goes quiet. It occurs every time in every patient. You’ll have the same pain but a different driver. (2) Surgery performed for pain in the emotional center is not going to work no matter how compelling the pathology.

Google Talks lecture – note that the host had 3 surgeons recommend surgery and he’s doing fine using the concepts outlined in the DOC process.

Phantom pain

The problem is similar to phantom limb pain. Before a person requires an amputation of his or her leg they’re usually in quite a bit of pain. Over half of amputees still feel their leg AND the pre-op pain they had before the amputation. How can that be? The source of pain is clear and an amputation is definitive. It’s a programming problem. Once these unpleasant circuits are embedded in your brain they are permanent.

One surgeon reported on the results of 11 patients who had their normally functioning arms amputated for pain. The source of the pain wasn’t identifiable. Guess what? None of them had any pain relief and now they had just one arm. It is somewhat of a disturbing article to read.

There is a naïve view that surgery is the definitive answer if everything else has been tried. It’s only the solution if you can see the problem and even then it may not be effective if the “pain switch” in your brain remains on.

Is your surgeon seeing the whole picture?

It turns out that the additional stress of surgery in the presence of a fired up nervous system is a bad idea. The medical literature has shown that anxiety, anger, depression, lack of sleep, length of pain, and taking high dose narcotics all portend a poor prognosis for any surgery. (3) A 2014 research paper out of Baltimore related that only 10% of surgeons were currently assessing these factors before making a surgical decision. The results of surgery were predictably poor without these variables being considered. (4)

Know your surgeon – before surgery

Optimizing surgical outcomes

About four years ago my staff noticed that patients who went through a self-directed structured spine care program, such as the DOC project, had outcomes that were better and the post-operative course was much easier. We call the protocol “prehab” (rehabilitation before surgery). We require that all of our patients who are considering elective surgery spend at least 8 weeks addressing the various aspects of their chronic pain. For some of the more complex situations, we may work them for over a year before his or her situation is optimized for a consistently good outcome. Unexpectedly, over 100 patients in the last several years with major structural problems cancelled their surgeries because his or her pain disappeared.

Out hunting elk

Rick was an active physically fit gentleman who had severe, almost extreme spinal stenosis between his 3^rd and 4^th lumbar vertebra. The diameter of a normal spinal canal is about 15 mm and his was down to about 4 mm. His leg pain was so severe that he was essentially wheelchair-bound for prior six months. His symptoms and stenosis were so severe that I changed my schedule in order to perform his surgery the next week. BTW, he was not buying any of this “DOC project.” Then he came down with a respiratory infection and we had to delay his surgery for a couple of weeks. I said, “Look Rick, just humor me and at least start the expressive writing.” About five days before his surgery he called me and said that he was feeling a little better. I replied, “That’s great but I am assuming that you still want to do the surgery?” He said that he did. On the Friday before his Monday surgery he cancelled his surgery because he felt fine. When I talked to him a couple of months later just to check in he was back in the hills hunting elk without any pain – with a four mm spinal canal. Several years later he has not undergone any surgery.

You’re not a machine

Remember that you cannot take your body to the shop for a repair and expect the same percent of success that you would for your car. Cars don’t have a pain system. There is nothing in the mechanical world that remotely resembles pain. Be careful regarding your final decision to undergo surgery? Ask yourself the following questions:

• Am I getting a consistently restful night’s sleep?
• Is my anxiety improving?
• Have I addressed my anger issues? Am I even connected them?
• Are my medications stable and at a reasonable dose?
• Am I optimizing my exercise regime?
• Do you really know the chances of success for your proposed operation?
• Are you willing to accept a significant chance of your pain become worse from the surgery – even without a complication?

Prehab – optimizing surgical outcomes

We now have our patients address these issues and more before every elective surgery. Why not?

1. Ballantyne J, et al. “Chronic pain after surgery or injury.” Pain: Clinical Updates. IASP (2011); 19: 1-5.
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
3. Chaichana KL, Mukherjee D, Adogwa O, Cheng JS, McGirt MJ. Correlation of preoperative depression and somatic perception scales with postoperative disability and quality of life after lumbar discectomy. J Neurosurg Spine 2011;14(2):261–267
4. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.

Video: “Get it Right the First Time”

The post Surgery is the Definitive Solution? first appeared on Back in Control.

The post Surgery is the Definitive Solution? appeared first on Back in Control.