Dorothy was a retired National Guard armed service member. Although she was not in the best physical shape, she was moderately active. Golf was her passion.

This is an example of a 12-level fusion from the 4th thoracic to the 3rd lumbar vertebra. Once the spine has healed, it is permanently stiff where it has been fused.

Nerve damage is often permanent

Two years earlier she had developed pain down her right leg and weakness of the muscles that elevated her right foot, a condition commonly know as “foot drop.”  She underwent a surgery called a laminectomy between her lumbar 3-4 and 4-5, to take the pressure off the nerves. Her leg pain quickly resolved, but the damage to the nerves causing the foot drop was permanent; so she wore a brace to keep her foot stable when she walked. Normally, foot drop cannot be reversed with any surgical procedure, since the damage has occurred inside the nerve.

Dorothy’s symptoms now consisted only of the persistent foot drop, and she was able to walk easily with the brace on her lower leg. Her spine was straight and she had no pain in her back or legs. I looked at her new MRI scan and it showed that the surgeon had successfully taken the pressure off the nerves to her foot. There was some generalized arthritis; but there is no correlation between spinal arthritis and back pain, as those of you who are familiar with my website have heard me say before.

Why??

If you are wondering, “Why would she need another surgery?” you are following a sound train of thought. We know that damage to the nerves causing foot drop is permanent, so how could more surgery help? Even if the prior surgeon had left some bone spurs behind, more surgery still would not improve the chances of the foot nerves regaining function.

We also need to weigh the implications and risks of the spinal fusion that was recommended for Dorothy:

• The surgery can take up to 10 hours.
• You are in the hospital for 5 to 7 days—longer if there is a complication.
• The complication rate is over 70%, with significant chance of problems such as infection, paralysis, blindness, hardware failure, screws damaging nerves, blood clots to the lungs, and death.
• The fusion takes around four months to heal.
• Your overall strength does not return for months.
• There is a 30% chance that the spine breaks down over the rigid rods.
• There is a chance that a fusion of this magnitude will cause long-term back pain.
• You lose all flexibility in the area of the spine fusion. Dorothy would lose much of her ability to twist (Think of her golf game) and it will be more difficult to perform simple tasks such as bending over to tie her shoes.

Benefits versus risks

I could go on about this operation and its downsides, because I perform it often—but only for tumor, infection, fracture, or if a patient is bent over and cannot straighten up. Words cannot describe how gratifying it is to return a person’s ability to stand up straight.  However, over my thirty-year career, I have gone through every possible complication with patients who have undergone this surgery. Eventually we reach a good result, but not without a fight.

I am careful to inform my patients of the risks involved with an eight-level fusion—not so much for legal reasons, but for them to understand the degree of commitment required of them to undergo the surgery. The benefits must outweigh the risks. Get it right the first time

For Dorothy, the risk was high and the benefit was zero. I recommended no further surgery.

The frequency of these operations has risen in the last few years. Be careful.

The post Eight-Level Spine Fusion? No! first appeared on Back in Control.

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In the first edition of my book, Back in Control, my advice was that if you had a surgical problem, get the surgery done quickly and engage in the rehab process after you recovered from the operation. I had felt that people in pain could not tolerated the extra burden created from a structural problem. I also thought that surgically correcting severe pathology would relieve the pain to the point that people would be compelled to move forward with their lives. However, I had many patients continue to do poorly in spite of a well-performed indicated operation. I was perplexed and could not predict when this would happen.

Inducing more pain

But I wasn’t aware of the research that shows there is a 40–60% chance of inducing chronic pain as a complication of any surgery if you operate in the presence of untreated chronic pain in any part of the body. It can become a permanent problem 5-10% of the time. (1) Chronic pain as a complication of surgery is not a well-known concept. If I had a neurological complication rate of 5%, I would not have remained in practice for long. This occurs even if the procedure goes well.

My staff pointed out that our patients that had gone through a structured rehab program prior to a procedure were doing much better, and we made a team decision to not perform surgery unless a given patient was sleeping, working on stabilizing medications, experiencing improvement in his or her anxiety/ depression and willing to deal with anger issues. We called the program, “prehab”, and asked our patients to fully engage for at least 8-12 weeks. When we considered major deformity surgery, the prehab might take up to a year.

Many patients did choose to go elsewhere, but the ones who stuck with it, consistently did better and frequently patients with significant structural anatomic problems cancelled surgery because their symptoms had improved or resolved. This turn of events was completely unexpected. It appears that as the nervous system calmed down that the pain threshold was elevated.

Four patients

I saw four patients within a two-week span that I had an almost the same conversation with regards to their decision to undergo surgery. All were professional men between the ages of 45-65. They had leg pain originating from an identifiable problem in their spine. The pain was severe enough that each wanted to have surgery, but they were all at least an 8 out of 10 on the anxiety scale and were sleeping poorly. Their stresses included seriously ill children, loss of jobs, marital problems, etc. and none of them were coping that well.

Can you live with your anxiety?

They were familiar with the DOC project but had not engaged with the concepts at a meaningful level. They were coming back for their second and third visits. Finally, I asked each of them the same question, “What would it be like if I could surgically solve the pain in your leg, but the anxiety you are experiencing would continue to progress over the next 30 to 40 years?” Their eyes widened with a panicked look and every one replied, “That would not be OK. I couldn’t live like this.” Each of them also grabbed his leg and asked, “Won’t getting rid of this pain alleviate my anxiety?” My answer was “No.”

Anxiety is a sensation generated by the body’s chemical response to a mental or physical threat. It is a deeply unpleasant sensation, and the intent is for you to take evasive action and survive. Although surgically removing the spur and pain will relieve the pain and some anxiety, it doesn’t come close to solving it. The essence of lowering anxiety is training your body to secrete less stress hormones.

The quest

I told them that although I would love to get rid of their leg pain with surgery, my bigger concern was their severe anxiety and possibly chronic pain. I recalled my 15-year battle with pain and anxiety. I was on an endless quest to find the one answer that would give me relief; especially for the anxiety. I also remembered the intensity of that need. At that moment I realized that each of these patients felt that by getting rid of the pain they could lessen or solve their anxiety.

It is actually the opposite scenario. As your anxiety resolves, it is common for pain to abate. Crippling anxiety is a solvable problem with the correct approach. That usually doesn’t include surgery. Also, after a failed surgery, another level of hope has been taken away.

Can you live with your leg pain?

Then I asked each of them that if I could resolve their anxiety but they would have to live with their leg pain, what would that be like? Although not completely happy about the scenario, they thought they could deal with it. It was more palatable than experiencing no improvement in their fear.

“No” to surgery

These patients didn’t want to jump to surgery and wanted to give the DOC program a try. Within six to twelve weeks their pain disappeared or subsided to the level where they weren’t even considering surgery. Although I know pain and anxiety are linked circuits, I had never realized that for many patients the pain relief they were asking for was really for peace of mind.

Conversely, I’ve had many patients over the years undergo a successful surgery for a severe structural problem with no improvement or worsening of their pain. Now I understand. “Neurons that fire together wire together.” Pain, anxiety, and anger are tightly intertwined. As long as the anxiety/anger pathways are fired up, they will keep the pain circuits firing.

Surgery may or may not help your arm or leg pain. It rarely solves neck or back pain. It really doesn’t work for anxiety. What relief are you asking your surgeon for?

Listen to the Back in Control Radio podcast Am I Operating on Your Pain or Anxiety?

1. Ballantyne J, et. al . Chronic Pain after Surgery or Injury. IASP (2011); 1-5.

The post Am I Operating on Your Pain or Anxiety? first appeared on Back in Control.

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