A patient’s story – spine surgery gone bad

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

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

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

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

My perspective

I am going simply list the issues in this situation.

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

Do You Really Need Spine Surgery?

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

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

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

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

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

Be careful

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

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

There is still hope

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

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

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

Questions for your surgeon

References

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

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Chronic pain infiltrates every aspect of life. You have pursued endless treatments with promise of relief and you keep being disappointed. Eventually, you may give up any hope of a cure. Most people aren’t anxious to undergo surgery but if it seems like a definitive solution and what else is there to do? Additionally, surgeons are likely to promise a good outcome. Why wouldn’t you choose that option?

Back pain surgery doesn’t work

Focusing on low back pain, there is a major problem. Fusion surgery for chronic back pain doesn’t work well. The reported success rate is around 25% (1, 2) The data also shows that you can induce or worsen pain after any surgery between 20-60% of the time when operating in the presence of chronic pain. (3) So the chances of making you worse are higher than the chances of success.

Surgery is not a “definitive solution”. It should only be considered for a defined structural problem. That is a lesion that can be defined on an imaging study (MRI, Xray, etc.) with symptoms that match the identified anatomical problem. You can’t fix something you can’t see. LBP is a non-specific symptom and its cause seldom identifiable. I am clear with all of my surgical patients that whatever arm or leg pain I can solve with surgery; it won’t help back or neck pain.

Deal with all the issues

Chronic pain is complex and each human being is unique. There’s a trend in medicine to recommend simplistic solutions to this multi-faceted problem. All the factors that affect pain need to be addressed simultaneously. Almost all treatments offer some benefit but none are effective in isolation. The variables include:

• Sleep
• Stress
• Physical conditioning
• Medications
• Life outlook
• Family relationships

You’re the only one who can solve your pain. It’s critical to take control of your care with the medical profession being the source of your information and guidance. If your mindset is, “I just want my pain to go away” or “Fix me” you have almost no chance of meaningful improvement.

What is happening in modern medicine is disconcerting. Providers are almost all on a volume demand where we are given just a few minutes per patient to figure out what’s going on. It is essentially impossible to understand the whole situation in a busy clinic setting, so we are recommending treatments based on limited information. When you show up in a surgeon’s office, they are going to either recommend surgery or not. A paper out of Baltimore shows that less than 10% of surgeons are assessing the known factors that affect the outcomes of surgery, which leads to predictably poor outcomes. (4)

My wake up call

Several years ago my staff noticed that patients who were taking charge of their own care were going through surgery with less pain, better rehab and more consistent long-term outcomes. Historically, my approach was to aggressively address surgical lesions and have the rehab done later. I felt that a person in chronic pain couldn’t tolerate the additional discomfort of an identified structural problem. Most patients did fairly well but a significant number were worse after a well-performed procedure for severe pathology.

About that time, I had a patient with tightly pinched nerves in his lower back. He had both back and leg pain. I tried to work with him for a few months by addressing the above-mentioned common sense variables. He wasn’t buying it. I was clear that surgery would not help the back pain but could help the leg pain. Sure enough the leg pain did disappear after I took the pressure off of the nerves and stabilized the unstable level with a fusion. I would have thought that relieving the leg pain would have made a big difference in his overall quality of life. However, his back pain became much worse and he became incredibly angry. When I reminded him about our pre-operative conversation about not relieving back pain, he went ballistic.

Then I came across scientific studies showing that operating in the presence of chronic pain can induce pain at the new surgical site. I made a decision then that if a given patient didn’t want to learn about the nature of pain and take responsibility for his or her own care, that I wasn’t the surgeon for them. Why would I offer a procedure in a scenario where the success rate was compromised?

Current protocol – prehab

For patients considering elective surgery, we want them first engaging in their own healing process for at least eight to twelve weeks. I encourage them to engage for as long as needed. Some will participate in prehab activities for several years. We want them to be:

• Getting a restful night’s sleep for at least a couple of months. Lack of sleep will induce chronic pain. (5)
• Actively addressing stress to the point where they feel a noticeable decrease in anxiety and frustration.
  • Am I operating on your pain or anxiety?
• Defining and stabilizing pain medications. At a certain dose, narcotics cause more pain by sensitizing the nervous system.
• Becoming more physically active.
• Educated
  • Understand the neurological nature of chronic pain.
  • Identify whether they have a structural problem that is amenable to surgery? Do they really understand the risks versus benefits?
  • Know that surgery won’t significantly help neck, thoracic or low back pain.
• Looking at harmful habits.
  • Stop smoking for at least six weeks prior to a fusion.
  • Address eating/ weight
  • Address any recreational drugs being used, including excessive alcohol?

All of these issues affect outcomes. It is not a complete list but it does address the core problems.

What happened?

After implementing a prehab process for all my elective cases, I lost a significant part of my practice. Many patients would see another surgeon, bypass prehab and undergo surgery. But what happened to my practice was unexpected. Not only was I consistently seeing better outcomes, but dozens of patients with severe pathology were cancelling surgery. Their pain had dropped to the point where it was not worth it to them to undergo surgery with its attendant risks.

These outcomes were entirely unexpected. I had no idea how powerful prehab activities could be! It is incredibly rewarding to see a patient become free of pain without exposing him or her to the risks of surgery. I have done surgery for long enough that I am well-aware of the fact there is no such thing as, “simple surgery.” Complications and poor outcomes are always unanticipated and no one (both surgeons and patients) thinks it will happen to them. It’s also enjoyable to see the patients consistently do well when I do perform the operation.

One important caution – this article is not relevant if you are experiencing neurological compromise such as acute leg or arm weakness, loss of balance or bowel and bladder control. There are situations where emergent or urgent surgery is warranted.

Juan

I had an older gentleman who was having difficulty walking because his legs hurt and felt rubbery from tightly pinched nerves in his lower back. I wanted to quickly recommend a laminectomy to decompress these nerves and he would have done well. He also couldn’t read English and I thought the chances of him successfully engaging in the DOC process (prehab activities) were limited. I held the line and he began to use the Back in Control website tools utilizing the Google translator. He kept holding off on doing surgery. He came in six months later for what I thought would be his final visit before deciding on surgery. When I asked him if he was ready for surgery, he started laughing. “What are you talking about? I am walking as far as I want and am out dancing a couple of times a week. My leg pain is gone.”

Variations of his story happen several times every week. If someone decides to deeply engage in the healing process, it is almost always just a matter of time before they succeed. It’s the length of time, which is unpredictable.

Spine surgery is risky and I would even argue dangerous. One of my former fellows was devastated recently when a young patient died from a blood clot to his lungs after an elective operation. The surgery had taken seven hours but had gone extremely well. I have seen many unexpected severe complications in my own patients. The decision to undergo surgery is a serious one. Every other possible option should be actively pursued. If your surgeon is not assessing or having someone else look at all the above-mentioned prehab factors, then it is your responsibility to challenge him or her. If there is not a specific identifiable structural problem, the decision for surgery needs to come off of the table. Chronic pain is solvable and surgery when it is appropriate can contribute to a successful outcome. It should never be performed without assessing an addressing all of the factors affecting your pain.

Video: Get it Right the First Time

1. Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
2. Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 190
3. Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
4. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
5. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.

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Asking for a referral

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

Dear Dr. Hanscom,

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

Peace, Steve

My response:

Hi Steve,

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

Best regards, David Hanscom

He quickly wrote back:

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

Thank you again! Steve

My reply:

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

His recent email:

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

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

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

Thank you! Grace & peace, Steve

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

Surgical patients cancelling surgery

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

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

Optimizing surgical outcomes

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

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

“Simple surgery”

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

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

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

Video: Get it right the first time

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

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The first book was based on my personal experience and observing the successes with my patients. A great deal of new neuroscience research has since been published, which both supports my treatment approach and explains the reason for its success. Reading the neuroscience literature has deepened my understanding of how the process works. On a personal note, I also developed severe arthritis in both of my knees. About six months into my ordeal I realized that I had developed chronic pain. I re-engaged with these tools and have experienced a marked improvement in my symptoms.

Here are some of the concepts that I have learned through the literature and observation:

• Emotional pain and physical pain are processed in the brain in a similar manner and are equivalent entities. (1) They both cause the secretion of adrenaline and cortisol. When you feel anxiety you are simply feeling the this hormonal surge. Therefore, anxiety is a chemical reaction to sensory input and is not primarily a psychological issue. The Neurophysiologic Basis of Chronic Pain Most patients, given a choice of getting rid of their physical pain versus mental pain would rather get rid of their emotional pain. Fortunately, as anxiety drops, adrenaline and cortisol levels decrease and the physical pain will diminish. Stress chemicals increase nerve conduction and pain by 30 – 40%. (2) Anxiety, anger and adrenaline

• In the first edition, I was emphatic that surgery for a structural problem should be performed more quickly since people in chronic pain don’t tolerate additional pain. My experience and the literature do not support that idea. If you operate in the presence of a fired up nervous system, the pain will frequently worsen and often dramatically. I now have all of my elective spine surgery patients engage in the tools outlined in Back in Control for at least 8 to 12 weeks. Surgical outcomes have been more consistent with less pain after surgery and a faster rehab. I also am no longer seeing some of the dramatic failures from a well-done surgery like I saw in the past. The name for this preoperative rehab process is “prehab”. Video: Get it Right the First Time

• What has been the most surprising turn of events is that during the prehab process I have witnessed dozens of patients become pain free that have severe pathology with matching symptoms. I had scheduled each of them for surgery and they cancelled it because their pain dramatically decreased. They did not want or need surgery. I now realize that you can calm down and reprogram your nervous system any way that you want with consistent practice of these tools. It has been rewarding seeing patients become free of pain without the cost or risk of surgery. Avoiding surgery by raising the pain threshold

• I have changed the name of the DOCC (Defined Organized Comprehensive Care) project to the DOC (Direct your Own Care). My book is not a formula. It is a framework that breaks down chronic pain into its component parts and my patients find their own personal solutions. I have watched hundreds of patients become pain free with this largely self-directed process. If someone does not want to engage in these concepts, whether or not they use my book, they cannot and will not get better. The one factor that predicts a good outcome is being truly open to learning and using your personalized version of the tools. DOC-A framework of care

• Research shows that the writing and ripping up exercise does not have to express just negative thoughts. Writing down any thoughts and feelings, either positive or negative is effective. Expressive writing is still the foundation of the DOC project. (3) Write and don’t stop

• These concepts apply to pain from any source in any part of the body. Interestingly, as the process depends on decreasing adrenaline, pain in multiple body areas will disappear about the same time.

John

I had a middle-aged patient who had suffered a significant fracture of the middle part of his back. His spine was bent forward almost 45 degrees. However, since it was just at one level he was able to compensate and was still balanced with his head centered over his pelvis. I would have quickly recommended surgery for it for ten years ago. Then I found out he had been suffering from severe anxiety since he was ten years-old and sleeping poorly. I put him through the prehab process, which included expressive writing, active meditation, normalizing his sleep and getting him more physically active.

He was initially unhappy with me delaying surgery, which would have corrected the deformity. However, the medical literature is clear that surgical outcomes are compromised without the above-mentioned issues being treated. He came back a few times asking for the surgery but was not really engaging in the project. I finally said, “Look, you are welcome to find another surgeon, but I am not going to put you through surgery until these problems are least partially solved.”

He came in a few weeks later with a huge smile on his face. His pain was gone and his anxiety was beginning to decrease. He was sleeping much better and his whole personality was transformed. I will admit that I thought he was going to get his surgery done elsewhere. I am still endlessly surprised and fascinated when my patients come out of their pain pathways, although we witness it every week.

New format

The new edition is organized around following format:

• Section One – The Evolution of Chronic Pain
• Sections Two – The Principles Behind the Solution
• Section Three – The Roadmap Out of Chronic Pain
• Section Four – Continuing Your Journey

I am excited about the new edition. I have learned how to clearly present these concepts, since I have a better grasp of these principles. I am seeing a higher percent of people engaging and improving. This edition reflects that experience as well as the recent advances in neuroscience that support it. I am looking forward to seeing how this whole process unfolds and this new edition is the next step in my journey.

Am I operating on your pain or anxiety?

1. Eisenberger N. “The neural bases of social pain: Evidence for shared representations with physical pain.” Psychosom Med (2012); 74: 126-135.

2. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166-173.

3. Smyth JM and James Pennebaker. “Exploring the boundary conditions of expressive writing: In search of the right recipe.” British Journal of Health Psychology (2008); 13: 1-7.

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