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.

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Hey David,

I was hoping I could ask you a surgery question. I know you do a lot of revisions.

There’s a guy who came to me in early 2014. He could not sit, lie down, walk or do anything to get relief from terrible pain. I referred him to a colleague who is a McKenzie certified therapist (emphasizing extension of the spine). He couldn’t help him. The guy just didn’t know how to get through the system and I think his physician handled his case, from what I can tell, poorly. He was about a month from his onset when he first came to see me and he hadn’t even had an MRI. Anyway he wound up having a two level fusion right out of the gate. Are You Kidding Me? Not a microdiscectomy; straight to fusion for an L4/5 paracentral herniation (this is a bulging disc and probably not the source of pain). A year later he’s worse off than he was before the surgery and that’s saying a lot. Video: Get it Right the First Time

His surgeon keeps turfing him back to physical therapy because he just doesn’t know what to do with him but we can’t help him.

Other than the fact that he’s still in such bad shape how do you know when a revision is appropriate? As we know, you can always find someone willing to operate. I was talking with a patient the other day who seemed really down and when I asked her she said her daughter was going to have another back surgery. Number eleven!!! “The Pit of Despair”

This guy is only 32 years old and he lives every day in terrible pain. We just don’t know what to tell him other than we can’t help him. It’s so scary. What I’m going through is a mild nuisance compared to what this guy faces every single day. And I made it to 55 before my “problems” began.

Hope you’re well. I began doing some Qigong everyday a week or so ago. I think it’s been good for my mind. Best regards, Mike

My reply

Hi Mike, The data shows that when you perform surgery in the presence of chronic pain that there is a significant chance that you can induce chronic pain at the new surgical site.(1) Of course you can also make the pain worse at the site of the pain. You already know my thoughts about spine fusions. They simply do not work for LBP. I see this scenario every week and is maybe the biggest driving force in pursuing the DOC project. He is a classic person who would respond to the tools in Back in Control, but often patients are so angry that they are not open to anything. I have learned to simply let go hopefully they are open in the future. If he would be willing to read the book AND begin the expressive writing I would be happy to talk to him. Otherwise, I have learned that my conversation is not productive. Physical therapy is helpful, but as you know, is best combined with treating the other factors that affect pain. I am personally re-engaging with the writing/ active meditation at a much higher level along with the gym and a better diet. My knees are finally turning the corner. It has been very humbling and enlightening experience. I am glad to hear you are moving forward. Let me know if I can be of some specific help. Best regards, David

Mike’s unsettling answer

I’ll give it a shot. I’ve thought about it in the past but I just don’t know if he’ll go for it. When I first met him I had all kinds of alarm bells going off, as did my colleague Henry, about how the whole process was unfolding for this guy. And we both told him so.  But he just did the passive patient thing and allowed himself to be carried by the currents of a very unplanned plan of care that he had no capable point person guiding him on.

But at this point what’s he got to lose? As I say about so many of the changes I’ve undergone in my approach to all this; “There are no atheists in a foxhole”.

This whole process has been such a, I don’t know what to call it – a revelation to me. After becoming a physical therapist I became aware there are a lot of people living in chronic, unsolved pain out there. But once you’ve walked a mile in their shoes the numbers of people out there living like this guy becomes staggering and frightening. Like most people I always felt so bad about the people who died young but never really considered people who lived with pain every day. I would have a fleeting thought of “glad that’s not me” and would dread them turning up on my schedule because they made me feel so helpless. My god – the self-centeredness of that mindset. These people made me feel helpless.

I’ve come to believe that in many ways the guy who dies of cancer at age 32 is better off than this guy who, at age 32, has to live the rest of his life in the kind of pain he faces every day. And everything that goes with it: the economic insecurity of trying to live on a monthly disability check, the loneliness of not being able to take part in a life like the other members of his cohort lead, the horrible boredom of being unable to work, have a career and to be so limited physically.

The way I’ve come to feel about it now often makes me think of your remark about how the “certain inalienable rights” to which we are all entitled fell one short in not including a right to live without pain.

Speaking of which I’m really glad to hear your knees are getting better. Mike

Basic human needs

First, not being in pain is a basic human need along with food, air, water, etc. When any of these needs are unmet the human body’s reaction will be intense. Maslow’s Omission

Abraham Maslow was a prominent psychologist who chose to look at the reasons why people thrived in life. He developed a well-known “hierarchy of needs” that he presented as stacked rows shaped in a pyramid. The bottom row includes: air, food, water, sex, excretion, and sleep. The top of the pyramid is, “self-actualization. It is difficult if not impossible to progress up the pyramid until lower needs are met. One need that he did not mention was, “not being in pain.” It is my feeling that it is one of the basic needs that belongs on the bottom row. Your reaction of feeling trapped and angry is completely justified when they are unmet. That is why becoming pain free requires multiple strategies. You cannot just will yourself out of it with positive thinking or mind over matter. Your Personal Brain Scanner

Secondly, I have also felt that chronic pain can be worse than having a terminal illness. I clearly recall the intensity of my feelings when I did not have any hope the pain might end or when that might be. Being in constant mental or physical pain is one of life’s most difficult stressors. It’s paradoxical that a beautifully designed system intended to protect you can also cause so much grief. The crushing aspect of chronic pain is that there appears to be no escape or an end in sight.

The feeling of being trapped was familiar to Viktor Frankel, a famous Jewish psychiatrist who survived WWII concentration camps. He wrote a classic book, Man’s Search for Meaning. It is striking that in spite of the extreme physical hardships Frankel endured, for him the most difficult part of the ordeal was not knowing if and when it was going to end—which is similar if not identical to what patients in chronic pain experience.”

Finally, it is now well-documented in many research studies that not working is bad for your mental and physical health – really bad. (2) The human body is designed for survival and does not perform well when not challenged. Additionally it has been demonstrated that working and having a sense of purpose actually slows down the aging process at the cellular level.

Phantom Brain Pain

If you are reading this post with complete disdain for all of these ideas please understand you are experiencing one of the symptoms of a stressed and over-adrenalized nervous system – obsessive thought patterns. I call it “phantom brain pain.” Similar to phantom limb pain these spinning circuits don’t stop and are unpleasant. It appears that Mike’s patient may be in this situation.

It is also well-documented that your brain physically shrinks in the presence of chronic pain and fortunately re-expands with successful treatment. (3) Adrenaline may be a factor in that it diminishes the blood flow to your brain. This phenomenon affects your perceptions and reasoning. Anxiety, Anger and Adrenaline

Between a decreased brain mass, diminished brain blood flow, obsessive thought patterns that seem like your reality, and anxiety you may not have the mental capacity to process new concepts.  You also may not really want to heal and/or you just want to be fixed. The only chance you have is to begin to engage in some basic tools to break up these irrational thought patterns. It is well documented that writing down your actual thoughts has an effect on doing this. I call it, “mechanical meditation.” Write Your Way Out of Pain

My plea to you is simply pick up a pen or pencil and start spewing out any of your thoughts on paper and immediately tear them up. It can and will break through these circuits. Just do it.

1. Perkins, FM and H Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
2. Waddell, G and Kim Burton. Is Work Good for Your Health and Well-Being? The Stationary Office, Norwich, UK, 2006.
3. Seminowicz DA, et al. Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function. The Journal of Neurosci­ence (2011); 31: 7540-7550.

The post When will the Pain Stop? first appeared on Back in Control.

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This is Scott, who is a personal trainer that I work out with on Tuesdays and Thursdays at 6 am. This is his picture at the gym one memorable Halloween. He’s a little unusual in that he laughs at us – the whole time we are working out. He pushes us hard and the more we “complain” the more he works us – and keeps laughing. Of course we also end up laughing. It doesn’t matter what lines we give him he will one-up us. It is impressive in that we have some excellent complainers in our group.

I am paying you for this??

It hit me one day that people pay me to do whatever I can to relieve their pain and I am paying Scott to inflict pain – some days quite a bit of it. Yet I come out of my workout invigorated and refreshed. My day is always better and my mood is light. That’s in spite of the fact that my patients keep asking me the rest of the day if I’m in pain. My back and right knee is stiff after my sessions with him. I limp and have a hard time getting out of the chair after a patient visit. Although I am uncomfortable I don’t really perceive it as pain either during the workout or the rest of the day. What’s going on? I don’t have a particularly high pain tolerance.

Choice

I think one reason is because I have a choice. I make a decision to get out of bed early and spend time at the gym. We have a great time in spite of a lot of physical sensations that are often not that pleasant. But I could always leave or quit working out with this group. With chronic pain you have no choice. You’re trapped by unpleasant sensations. Feeling trapped creates anger and over time it can evolve into a rage. Contrast the same uncomfortable sensations combined with deep anger versus laughing and having a complete choice over how much pain you are going to allow to be inflicted on you.

Interpreting signals

Every time the body sends a pain signal to your brain it has to be interpreted as pleasant or unpleasant. When the sensation is combined with a pleasurable experience (and I hate to admit to Scott I am having a good time) it’s a completely different situation then when these sensations are combined with fear and anger. The final perception is dramatically different. Make no mistake about it. Pain is a perception and is interpreted only through your nervous system. It is confusing in that although the pain is felt at the point of origin it is perceived only in your head. All pain is “in your head. If you think otherwise, “wake up”. Video: Explain Pain

The quest

If you are on a quest to “find the source” of your pain or you’re convinced that “The doctor is missing something” you’re stuck. In fact you’re being trapped by the same disease that’s also contributing to your chronic pain – the Neurophysiological Disorder (NPD). Obsessive thought patterns are one of the classic symptoms that also blocks treatment. I liken them to phantom limb pain where pain persists in the arm or leg after it is amputated. The pain circuits keep spinning. So can obsessive thought patterns. Patients frequently have undergone many tests for years without an answer and can’t stop going to the doctor to have more of them done. The need to “find an answer” is an endless pilgrimage. The term I used for my search was an “epiphany addict”. I kept having major “breakthroughs” that would last for a few days or weeks but there was no meaningful change in the overall quality of my life.

Your choice

Right now you may not feel like you have much say about your pain. But you do have a choice to learn about the various components, engage in effective treatments and take full responsibility for solving it. I enjoy my workouts with Scott and my friends because I have a choice. I experienced years of chronic pain in where I had no choice. It was unpleasant beyond words.

I ended my quest for an “answer” in 2002 in that somehow I realized that the answer to my pain was there was no answer.  I made a decision to live my life with or without the pain. It happened on Mother’s Day. As I took back complete control of my life, my pain eventually disappeared. I didn’t make the decision in order to get rid of the pain. It was an unexpected bonus. It’s what happens to my patients as they reach the point where they make that same choice. With a deep commitment, becoming pain free is the rule, not the exception.

Make a choice to live. You only have one shot at this life.

The post “I’m Paying You to Inflict Pain??” first appeared on Back in Control.

The post “I’m Paying You to Inflict Pain??” appeared first on Back in Control.

An extreme example of memorized pathways is the problem of phantom limb pain. When patients require an amputation for diabetes or peripheral vascular disease, the body part is deprived of blood and oxygen and the response is often extreme pain. A heart attack is a classic example of the heart muscle not being supplied with enough oxygen to keep it alive. In phantom limb pain, we can identify the source of the pain–the body recognizes that there isn’t any blood being supplied to the missing limb, so it triggers a pain response. Now let us look at the example of RSD of an arm.

Reflex Sympathetic Dystrophy

RSD stands for “reflex sympathetic dystrophy.”  The sympathetic nervous system is a separate nervous system from the main nerves in your body.  It causes blood vessels to expand or constrict, increases your heart rate, opens or closes the pathways to your lungs, influences the skin by causing sweating or clamminess, and more.

For reasons that are unclear, a person can have a major or minor trauma to an arm that will set off an extraordinarily painful process where the whole arm becomes extremely painful and it DOESN’T STOP.  You don’t get used to it and it is considered one of the worst pain syndromes that exist.  The arm will usually become cold and discolored and intermittently swell.  Even the slightest touch can cause agony.  Unfortunately, in the face of clear manifestations of the problem, these patients often are labeled by their doctors as having psychological issues–the “pain must be in their head.”  In addition to experiencing extreme agony, they are not believed.  Talk about frustrating.

Normal arms amputated

In 1995, a paper was published that reported on a series of 28 patients who underwent an amputation of their arm for relief of their pain.  Guess how many achieved relief of their arm pain? Two. The anatomy of these amputated arms was NORMAL.  There was not a lack of blood supply.  There was no soft tissue damage from any trauma.  They just experienced an unexplained imbalance of their sympathetic nervous system.

Please think about this report for a while. This is the way the nervous system works. It is how we learn everything. With repetition, the brain lays down a substance called myelin that cements these circuits into your brain. The repetition of chronic pain impulse is stronger than almost any other learned behavior. These are not imaginary sensations. They are strong deeply etched-in pathways. Chronic pain pathways are like telephone cables compared to the small bare wire of a normal pain pathway.

Having a normal functional arm amputated is an act of desperation. The nervous system must be taken into account with or without surgical intervention.

I talk about this in the Video: Memorizing the Circuits: Phantom Pain.

JYR, BF

The post Normal Arms Amputated first appeared on Back in Control.

The post Normal Arms Amputated appeared first on Back in Control.

Thoughts are also memorized and can become obsessive circuits. Unfortunately, the brain becomes more focused on negative thoughts because there is natural tendency to suppress them. Although you make think you are successfully conquering them, you are actually giving them more neurological attention.  “The surgeon screwed up my back.” “I can’t get out of bed.” “The pain is ruining my life.” These circuits can take on a life of their own, running on a constant loop. If left unchecked, they turn into a serious obstacle to recovery; one that’s not a psychological issue as much as it is a “programming” issue. You can develop tools to break the cycle of negative thinking, but first you have to conceptualize how the brain works.

The Talent Code

Dan Coyle wrote a book, The Talent Code, where he points out how genius is created. He also makes a nice connection to neuroscience research. There are three factors contributing to high-level learning: 1) Deep learning 2) obsessive repetition 3) Master coaching. The ideas is to engage in repetition of specific moves within a narrow range. I feel the same concepts apply to way the brain processes pain. Reading this book has been helpful for my patients to better conceptualize the formation of pain circuits. Motivated by The Talent Code

Phantom limb pain

Neurological connections associated with pain will often continue to function, even if the offending stimulus is removed. A classic example of this is “phantom limb” pain. It occurs in patients who require an amputation, usually because blood supply to the limb is compromised by vascular disease. Common causes are diabetes or atherosclerosis, when there is not enough blood to sustain viability to the limb. Prior to the amputation, lack of oxygen causes the limb to become very painful. After the limb is removed, up to 60% of patients feel the pain as though the limb were still there.  Almost 40% of sufferers characterize the pain as anywhere from distressing to even more severe than before. (4)

There is not a more definitive operation than removing the entire source of the pain by performing an amputation. The nervous system does not even know the leg is gone, and it still feels the same sensations and pain. From those of us who have the visual experience of performing these amputations, this is a dramatic example of the power of the nervous system. It is also a reminder that the brain also is an extremely complex sophisticated computer, which is programmable. To “de-program,” it takes much more than will power.

Body image disorder

Another example of a situation where a stimulus was removed, but the brain couldn’t be “de-programmed,” was a major reconstructive spine surgery that I performed in my third year of practice. Brad, the patient, was a 27 year-old athletic banker who had a moderate “hunchback” deformity called kyphosis. He was experiencing a lot of pain in middle of his back associated with it.  The deformity was about an 80- degree forward curve (the highest normal value is around 55 degrees).  I was hesitant to perform surgery, as it is a major five to six hour procedure with significant risks.  The surgery went well, however, and his curve was reduced to 50 degrees.  Post-surgery, it became clear that his body image had been his major issue, and it didn’t change at all nor did his pain.

There are many examples of negativity. However, the point is that once the nervous system becomes fixated on one specific negative thought pattern, it is not going to stop on its own. It’s possible to break the circuit but it takes very specific techniques.

Video: Standard Stress Skills Inadequate

The post 3 – Memorization of Neurological Circuits first appeared on Back in Control.

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