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.

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

A pinched 5th lumbar nerve?

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

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

Jack’s story

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

POSTPONE YOUR BACK SURGERY!

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

Spontaneous onset

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

Wait a minute

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

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

Pain free

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

Resources

Here are the other books I’ve found valuable:

1)     Unlearn Your Pain, by Howard Schubiner, MD

2)     Forgive For Good, by Fred Luskin, PhD

3)     The Hoffman Process, by Tim Laurence

4)     Healing Back Pain, by John Sarno, MD

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

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

Jack

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

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

Modern neuroscience 

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

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

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

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

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