The business of medicine

I am not going to spend a lot of time on this aspect of the problem, but the business of medicine is focused on profits, and you are the revenue source. If it were otherwise, you’d see a focus on outcomes, which has rarely happened. When outcomes are looked at, it is in the context of that procedure and not compared to the application of know proven effective treatments, which don’t generate revenue. One paper showed that only 10% of orthopedic spine surgeons and neurosurgeons follow the guidelines for the non-operative treatment for chronic back pain.¹ We are not implementing what we already know about excellent spine care.

People argue that surgery is the last resort. That is true in less than 10% of cases for chronic low back pain.² There may be an infection, fracture, or tumor. Surgery is also usually effective in relieving sciatica from a pinched nerve, but that is not low back pain. There is not a single paper that shows that a back fusion for back pain is better than carefully applied proven treatments, and in fact the opposite is true.³

There are other choices

There are plenty of other options that do work. There are many studies showing that structured multi-pronged approaches do solve chronic pain, but they are usually not covered by insurance and not readily available.^4,5 Chronic pain is complex that can’t and won’t respond to random single treatments. We are not systematically covering the basics that affect the perception of pain.

For example, there is deep research showing the adverse effects of poor sleep on health and pain. Lack of sleep actually causes chronic low back pain, and it was not shown to be the other way around.⁶ One bad night of sleep will increase your pain by 50% the next day.⁷ There is more correlation of disability with inadequate sleep than there is with pain.⁸ Yet for those of you who have undergone surgery for back pain, how many of you were asked about the quality of your sleep and were you getting adequate sleep before you made the final decision to undergo surgery? How many of you had a major surgical decision made on the first visit with your surgeon?

Operating on normally aging spines

We currently have a scenario where there are hundreds of thousands of spine fusions being performed annually on normally aging spines.⁹ Disc degeneration, bone spurs, ruptured discs, herniated discs, arthritis, bone-on-bone, collapsed discs have been clearly shown to NOT be a cause of chronic back pain.¹⁰ This is supported by the data that shows the success rate for a spine fusion for back pain is < 30% at two-year follow up.^11,12

What is also not widely known is that when any procedure in any part of the body is performed in the presence of untreated chronic pain, you will induce chronic pain at the new surgical site between 30-60% of the time for up to a year.^13,14 Five to ten percent of the time, the pain will be permanent. For example, if you have been suffering from chronic neck pain and you have a hernia repair, the site of the hernia surgery will become painful. It is an operation that is generally almost painless.

For those of you in pain, this is a big number. Additionally, the impact of chronic pain on a person’s quality of life has been shown to be equivalent to suffering from terminal cancer.¹⁵ No one believes you. I will never forget a study I read many years ago about patients who had been suffering from chronic abdominal pain and were then diagnosed with advanced pancreatic cancers. Over 50% of them were relieved that someone had found something wrong.¹⁶

I will just briefly comment that there is ALWAYS something wrong when suffering from chronic pain. It is explained by your physiology being in a sustained flight or fight mode and it will break down your body relatively quickly. Your own tissues are being destroyed by your own immune system.

Dashed hopes

The purpose of this blog is to introduce a forum where people can share their surgical failures. It is titled, “Surgical Stories of Despair.” There are some successes, and I am happy that you might be one of them. However, many stories fall under what I term, “The catastrophe Index.” The destruction wrought on peoples’ lives can be complete. In one series of over 300 patients, there were nine suicides. That was unpublished data. I have also witnessed more than a few suicides over my career, and I personally was almost one of them. In addition to being angry about being trapped in pain, many people are legitimately angry about the surgery not only being ineffective, unnecessary, but also making them worse. Unfortunately, anger represents a very fired up nervous system and inflammatory response, which sustains the pain. It is a horrible cycle.

A small sampling of surgical disasters

I am going to provide some short examples of true surgical catastrophes that I am continuing to hear about. There is one common theme in that NONE of them needed surgery, they would have done well with a systematic thoughtful approach to their situation, and ALL of them had spines that were normal for their age. The more recent trend that is incredibly damaging is that more levels are being fused with a higher complication rate and more limitation of motion.¹⁷

Fused from her skull to pelvis

A girl in her mid-20’s is under the care of one of my physiatry colleagues. Almost by definition, a person this age has a spine with normal anatomy. When do surgery, we always try to limit the number of levels as each level fused detracts from normal motion. We avoid fusing the first to the second vertebrae in the neck as it limits your ability to rotate your head. It is only under rare circumstances we fuse the skull to the spine because you can’t flex your chin or look up. She not on had her skull fused to her neck, she was fused to her pelvis. She has essentially been placed into an internal straight jacket. She can’t move anything. She will spend the next 50 or 60 years of her life in this condition. Additionally, the tissues over the back of her neck pulled apart under the skin and she has a deep concavity in the back of her neck. None of this is reversible.

Fused from her skull to her neck

There was a center on the East Coast that routinely fused people from their skull to their neck. They would have patients send in their MRI’s scans and surgery would be scheduled over the phone. She was not only fused her from her skull to her neck, but the plate was placed too high, and it eroded through her skin. She could not rotate her head, look up or down and her pain was much worse. Her pre-op MRI of her neck was not only normal, but it also looked 20 years better than her age. Why would anyone think that creating a mass of bone and scar tissue would be better than her normal anatomy?

Fused from her neck to the pelvis

I did a consult years ago on an older woman who was extremely physically active. She had been suffering from muscular mid-thoracic pain for a couple of months after working out too hard at the gym. Her spine was completely normal for any age. On the first visit, it was decided she needed surgery. She was fused from her neck to her pelvis. They fused her in a position that tilted her forward and too far to the left. They had to break through the fusion to redo it. Each surgery took about 10 hours to perform. She went from a normal lifestyle to being housebound, was taking high doses of narcotics for severe total spine pain and had what appeared to be a psychotic break. She wanted the surgery reversed, which wasn’t possible.

Other cases

I could write a book on the number of catastrophic cases I have seen over my career and it has become much worse over the last decade. I also have enough of my own surgical failures to understand the impact on my patients lives. Most surgeons do become more careful about recommending surgery as their career progresses. None of like poor outcomes. That being said, an attorney friend of mine researched the literature and noted that about 15% of surgeons have the profile of a sociopath.¹⁸ Your problem is that you don’t know who that person is, and they tend to be personable and convincing. He or she may also frighten you into doing surgery for a harmless situation. There are few truly emergent spine problems, and they are obvious when they occur.

Here are some brief descriptions of some more surgical misadventures.

• Three lumbar fusions and became psychotic
• Routinely performing five-level fusions on the lumbar spine through the abdomen. There is never a reason to perform this surgery. Even if there were, it should take only three to four hours. These surgeons were taking 18 hours and they are still doing them.
• 29 surgeries in 20 years and now fused from his neck to his pelvis
• 15 surgeries in 18 months; the first surgery should have been a simple laminectomy and he is also now fused from his neck to his pelvis.
• A businessman who lost bowel and bladder function and became partially paralyzed
• A friend of one of my neighbors is completely disabled after two failed spine surgeries. He has gone from being a successful professional to going home to live with his parents.

“Enough”

When I ran across a young man who was significantly paralyzed by an operation he did not need, I finally quit my surgical practice to create an awareness of the magnitude of the problem. The business of medicine is actively pushing surgeons to perform surgery. They are being held accountable to production quotas instead of the quality of the outcomes. In fact, there are computer programs measuring physicians’ contribution to the profit margin.

You should not have to be the one to decide on the necessity of spine surgery. It is your surgeon’s responsibility to make sure that every possible treatment has been utilized and only operate if there is a problem that is amenable to surgery. Back pain is not one of them, especially when the anatomy is consistent with normal wear and tear. It is true that your spine becomes less flexible as you age, but do you think a spine fusion will make it more flexible? As one of my colleagues pointed out, if you decide that normal spines need surgery, there is an abundant supply of them.¹⁹

 You can make a good spine surgical decision

I wrote I book, Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice.²⁰ It breaks down the decision to perform surgery into two variables: 1) the anatomy – amenable to surgery or not 2) the state of your nervous system – calm or hypervigilant. There are then four distinct categories of decision-making. The intention is to give you and your providers clear direction on what to do. You cannot go back. Once you have had a spine fusion, your spine has been surgically traumatized.

I am not happy that I felt the necessity of writing this book. This decision is the final responsibility of your surgeon. I am even less happy about feeling compelled to stop my surgical practice at the peak of my career. With the combination of methodically preparing patients for surgery, focusing clear indications, and consistent rehab after surgery, we were seeing few failures and wonderful outcomes. We were just following what the data has outlined for decades.

The problem is complex

Just to be clear, I am not faulting most surgeons in this situation. We worked hard to get where we are and want to make people better. I was one of them and we make our decisions consistent with our training. I spent the first eight years of my practice aggressively performing fusions for LBP. It wasn’t until the data began to come out with a 22% success rate that I stopped doing them.^21,22 I would have had no awareness of how to successfully treat chronic back pain without having experienced severe chronic pain myself for over 15 years. It is how the current approach, The DOC (Direct your Own Care) Journey evolved. It not only reflects the concepts in my book, Back in Control: A Surgeon’s Roadmap Out of Chronic Pain,²³ but also the most recent basic science neuroscience research.

“Surgical Stories of Despair”

Here is the link to the “Surgical Stories of Despair.” I am sorry that you may be one of them. Although there are many surgical success stories, it is important for the world to know how bad it can be to aid in making a better surgical decision. Please share your story. It needs to be told.

References

1. Young AK, et al. Assessment of presurgical psychological screening in patients undergoing spine surgery. Journal Spinal Disorders Tech (2014); 27: 76-79.
2. Nachemson A. Advances in low back pain. Clinical Orthopedics and Clinical Research (1985); 200: 266-278.

3. Fritzell P, et al. Swedish Lumbar Spine Study Group. Lumbar fusion versus non-surgical treatment for LBP. Spine (2001); 26: 2521-2532.
4. Brox JI, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine (2003); 28(17): 1913 – 1921.
5. Cherkin DC, et al. Effect of mindfulness-based stress reduction vs. cognitive behavioral therapy or usual care on back pain pain and functional in adults with chronic low back pain. A randomized clinical trial. JAMA (2016); 315:1240-1249. doi:10.1001/jama.2016.2323

1. Agmon M and G Armon. Increased insomnia symptoms predict the onset of back pain among employed adults. PLOS One (2014); 8: e103591. pp 1-7.
2. Ohayon MM. Relationship between chronic painful physical condition and insomnia. Journal of Psychiatric Research (2005); 39:151 – 159. Doi:10..1016/j.jpsychires.2004.07.001.
3. Zarrabian MM, et al. Relationship between sleep, pain and disability in patients with spinal pathology. Archives of Physical Medicine and Rehabilitation (2014); 95: 1504-1509.

9. Deyo RA. Lumbar degenerative disc disease: Still more questions than answers. The Spine Journal (2015); 15: 272 – 274.
10. Boden SD et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation. Journal of Bone and Joint Surgery (1990); 72: 403 – 8.
11. Franklin GM, et al. Outcome of lumbar fusion in Washington State Workers’ Compensation. Spine (1994); 19:1897–903.
12. Carragee E, et al. A gold standard evaluation of the ‘discogenic pain’ diagnosis as determined by provocative discography. Spine (2006); 31:2115-2123.
13. Perkins FM and H Kehlet. Chronic pain as an outcome of surgery: A Review of Predictive Factors. Anesthesiology (2000); 93: 1123 – 1133.
14. Ballantyne J, et al. Chronic pain after surgery or injury. Pain: Clinical Updates. IASP (2011); 19: 1-5.
15. Fredheim OM et al. Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients. Acta Anaesthesiologica Scandinavica (2008); 52: 143 –
16. Source unknown
17. Martin BI et al. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (2007); 32: 382 – 387.
18. The Annual Business of Spine Conference, Methow Valley, WA.
19. Martin BI et al. Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015. Spine (2019); 44: 369 –
20. Hanscom DA. Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice. Vertus Press, Oakland, CA, 2019.
21. Franklin GM, et al. Outcome of lumbar fusion in Washington State Workers’ Compensation. Spine (1994); 19:1897–903.
22. Carragee E, et al. A gold standard evaluation of the ‘discogenic pain’ diagnosis as determined by provocative discography. Spine (2006); 31:2115-2123.
23. Hanscom, David. Back in Control: A Surgeon’s Roadmap Out of Chronic Pain. Vertus Press, Oakland, CA, 2016.

The post Surgical Stories of Despair first appeared on Back in Control.

The post Surgical Stories of Despair appeared first on Back in Control.