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.

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

Do You Really Need Spine Surgery?

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

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

A life changing complication

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

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

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

Didn’t need it

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

“If I Were Your Spine Surgeon”

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

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

Anxiety

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

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

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

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

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