• Chronic mental and physical pain are complex. Isolated interventions cannot and don’t work.
• Surgery is often considered a “definitive solution.” For chronic symptoms, it is not. It is simply one tool.
• Only two factors must be considered to make a decision regarding undergoing surgery – the anatomy and the state of your nervous system.
• Please make the right decision for you and make sure you know your surgeon and he or she knows you. A wrong decision can destroy your life.

Surgery on a normal neck??

Last week, I reviewed the films of a young girl who had been in a low speed car accident and was suffering from chronic neck pain. Her attorney sent her to a spine surgeon, who want to perform a five-level fusion of her neck. Her MRI was COMPLETELY normal with minimal bulges and no pinched nerves. Additionally, even if there was disc degeneration or arthritis, these factors have been documented to NOT be a cause of neck pain.

As a complex spine surgeon, I routinely saw patients with multiple failed surgeries with devastating effects on their lives. Most of the time when I reviewed the original imaging studies done prior to any surgery, there were no abnormalities other than normal changes you’d expect with ageing. Operating on a normal ageing spine can only be damaging, yet somehow the medical profession has held up surgery as a definitive solution regardless of the anatomy. It is only an answer if there is something structurally wrong.

I don’t what will happen with her as I am only peripherally involved in her case. There is nothing in any aspect of our medical training that says we should operate on a normal spine. Unfortunately, a five-level fusion is not only risky, but a significant amount of normal motion is gone, and there is a high chance that she will have neck problems indefinitely.

Making the correct decision about spine surgery

The decision of whether to undergo a spinal surgery is not as difficult as you might think. There are just two factors to consider that enter into the decision. One is the anatomy and the other is the state of your nervous system.

Is there a clearly identifiable source of your pain causing symptoms that correspond to it?  Or is it arising from irritation of tissues that cannot be seen on an imaging study?

The second factor is the state of your nervous system. If you are feeling stressed for more than three months, the body’s chemistry is on “high alert”, which affects every cell in your body, including the speed of your nerve conduction and inflammatory state of your brain. (1) You will not only experience more pain, your capacity to cope with it is compromised.

The other issue when you are feeling trapped is that your brain activity switches from the neocortex (thinking region) to the lower parts of the brain (survival). So, you cannot physiologically think clearly and by definition, your decision-making will be flawed. You are not going to be thinking about philosophy while you are running from the lion.

With these two variables of the anatomy and state of your nervous system, there are four scenarios to consider:

• IA—Structural lesion, low risk for chronic pain
• IB—Structural lesion, at risk for chronic pain (high stress)
• IIA—Non-structural lesion, low risk for chronic pain
• IIB—Non-structural lesion, at risk for chronic pain (high stress)

An overview of how this looks is presented in this grid:

The Treatment Grid

The implications of this grid are important in making your decisions, and can be the basis of discussions regarding the role of surgery in your care. I quickly observed early in my practice that if a patient was not under a lot of stress (Type A) then outcomes were consistently positive if a structural problem (Type I) was solved. However, if that same person was in the midst of a major personal or professional crisis, then the results were less predictable. Surgery might have still been helpful but the other factors needed to be addressed.

Patients who don’t have a lot of extra stress and are experiencing pain without a positive imaging study (Type IIA) simply do not want or request surgery. Why? It is just pain that will resolve and it usually does.

The biggest problem we have in spine surgery is performing surgery on people who are stressed and the source of pain can’t be identified. Since mental and physical pain are processed in a similar area of the brain with the same chemical response of inflammation, adrenaline, histamines, and cortisol, the pain is often intense and people become desperate. First of all, surgery is never indicated without identifying the cause (Type II – non-structural). So the chances of success are already low, and then you add in the other factors that have been shown to adversely affect surgical outcomes (poor sleep, anxiety, depression, fear avoidance, poor physical conditioning, smoking, duration of pain, younger age). It is well-documented that there is a significant chance of patients getting worse.(2) It is surgery being aggressively performed in this group that is creating a lot of ongoing pain, suffering, and disability. Do not allow this to happen to you.

I quit

I was watching so many people experiencing catastrophic outcomes from surgery on normally ageing spines that I could not do it anymore. Additionally, I was witnessing hundreds of patients breaking out of chronic mental and physical pain with minimal resources and no risk. The factor that predicted success was a person’s willingness to learn and engage in the healing journey. The greatest block was patients feeling that something was being missed and that surgery was the only option.

You might be thinking to yourself that you had a back or neck fusion and it was successful. I also saw many of those patients. I think that is great and I am happy if worked for you. However, I also saw those people that were five to ten years out from a successful operation whose spines were breaking down around the fusion. These were often complex problems with limited options.

Resources

I wrote a book in 2019 that presented my decision-making over the last 15 years of my career. I am not against surgery at all if the problem is clearly identifiable and my patient’s condition was optimised before surgery. The research is clear on what should be done to accomplish this. Why would you not want to have your chances of success maximised? Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice provides the information you need in enough detail for you to make a better decision.

I also created two options for an action plan to optimise your condition prior to surgery. One was an app and the other a computer-based course. They are called, The DOC (Direct your Own Care) Journey. They provide a foundational knowledge base that you can build on and take control of your own care. Either one is the most effective by spending 15-20 minutes a day with them, as it requires repetition to learn the skills to regulate your body’s physiology.

Here is a link to the rest of my efforts that address a wide range of mental and physical disease states. It appears that most chronic diseases are caused by your body being exposed to sustained levels of stress chemicals and healing occurs in the presence of safety.

I need your help

The situation is getting much worse with bigger operations being performed with a higher complication rate. It should not be this way. It is the medical profession’s responsibility to listen, talk to you, and offer well-documented effective treatments. There is not one research paper in the last 60 years that has shown that a fusion works for back or neck pain compared to an organised rehab approach.

My efforts have helped many people individually, but the juggernaut of aggressive surgery is moving forward while non-operative resources are being eliminated. The only chance of slowing all of this down is from a grass roots effort. I am asking each of you to do what you can to share the message that chronic pain is solvable using research-based principles, which includes appropriate surgery. There is no data supporting spine surgery on normally ageing spines. Those of you suffering from failed spine surgery already know this all too well.

References

1. Chen, X et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166 – 173.
2. Perkins, FM and H Kehlet. “Chronic pain as an outcome of surgery: A Review of Predictive Factors.” Anesthesiology (2000); 93: 1123 – 1133.

The post Make the Right Decision About Spine Surgery – The Grid first appeared on Back in Control.

The post Make the Right Decision About Spine Surgery – The Grid appeared first on Back in Control.

Last week, I reviewed the films of a young girl who had been in a car accident and was suffering from chronic neck pain. Her attorney sent her to a spine surgeon, who wanted to perform a five-level fusion of her neck. Her MRI was COMPLETELY normal with minimal bulges and no pinched nerves. Additionally, even if there was disc degeneration or arthritis, these factors have been documented to NOT be a cause of neck pain.

As a complex spine surgeon, I routinely saw patients with multiple failed surgeries with devastating effects on their lives. Most of the time when I reviewed the original imaging studies done prior to any surgery, there were no abnormalities other than normal changes you’d expect with ageing. Operating on a normal ageing spine can only be damaging, yet somehow the medical profession has held up surgery as a definitive solution regardless of the anatomy. It is only an answer if there is something structurally wrong.

I don’t know what will happen with her as I am only peripherally involved in her case. Nothing in our medical training says we should operate on a normal spine. Unfortunately, a five-level fusion is not only risky, but a significant amount of normal motion is lost, and there is a high chance that she will have neck problems indefinitely.

Making the correct decision about spine surgery

The decision of whether to undergo a spinal surgery is not as difficult as you might think. There are just two factors to consider that enter into the decision. One is the anatomy and the other is the state of your nervous system.

Is there a clearly identifiable source of your pain causing symptoms that correspond to it?  Or is it arising from irritation of tissues that cannot be seen on an imaging study?

The second factor is the state of your nervous system. If you are feeling stressed for more than three months, the body’s chemistry is on “high alert”, which affects every cell in your body, including the speed of your nerve conduction and inflammatory state of your brain. (1) You will not only experience more pain, your capacity to cope with it is compromised.

The other issue when you are feeling trapped is that your brain activity switches from the neocortex (thinking region) to the lower parts of the brain (survival). So, you cannot physiologically think clearly and by definition, your decision-making will be flawed. You are not going to be thinking about philosophy while you are running from the lion.

With these two variables of the anatomy and state of your nervous system, there are four scenarios to consider:

• IA—Structural lesion, low risk for chronic pain
• IB—Structural lesion, at risk for chronic pain (high stress)
• IIA—Non-structural lesion, low risk for chronic pain
• IIB—Non-structural lesion, at risk for chronic pain (high stress)

An overview of how this looks is presented in this grid:

The Treatment Grid

The implications of this grid are important in making your decisions, and can be the basis of discussions regarding the role of surgery in your care. I quickly observed early in my practice that if a patient was not under a lot of stress (Type A) then outcomes were consistently positive if a structural problem (Type I) was solved. However, if that same person was in the midst of a major personal or professional crisis, then the results were less predictable. Surgery might have still been helpful but the other factors needed to be addressed.

Patients who don’t have a lot of extra stress and are experiencing pain without a positive imaging study (Type IIA) simply do not want or request surgery. Why? It is just pain that will resolve and it usually does.

The biggest problem we have in spine surgery is performing surgery on people who are stressed and the source of pain can’t be identified. Since mental and physical pain are processed in a similar area of the brain with the same chemical response of inflammation, adrenaline, histamines, and cortisol, the pain is often intense and people become desperate. First of all, surgery is never indicated without identifying the cause (Type II – non-structural). So the chances of success are already low, and then you add in the other factors that have been shown to adversely affect surgical outcomes (poor sleep, anxiety, depression, fear avoidance, poor physical conditioning, smoking, duration of pain, younger age). It is well-documented that there is a significant chance of patients getting worse.(2) It is surgery being aggressively performed in this group that is creating a lot of ongoing pain, suffering, and disability. Do not allow this to happen to you.

I quit

I was watching so many people experiencing catastrophic outcomes from surgery on normally ageing spines that I could not do it anymore. Additionally, I was witnessing hundreds of patients breaking out of chronic mental and physical pain with minimal resources and no risk. The factor that predicted success was a person’s willingness to learn and engage in the healing journey. The greatest block was patients feeling that something was being missed and that surgery was the only option.

You might be thinking to yourself that you had a back or neck fusion and it was successful. I also saw many of those patients. I think that is great and I am happy if worked for you. However, I also saw those people that were five to ten years out from a successful operation whose spines were breaking down around the fusion. These were often complex problems with limited options.

Resources

I wrote a book in 2019 that presented my decision-making over the last 15 years of my career. I am not against surgery at all if the problem is clearly identifiable and my patient’s condition was optimised before surgery. The research is clear on what should be done to accomplish this. Why would you not want to have your chances of success maximised? Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice provides the information you need in enough detail for you to make a better decision.

I also created two options for an action plan to optimise your condition prior to surgery. One was an app and the other a computer-based course. They are called, The DOC (Direct your Own Care) Journey. They provide a foundational knowledge base that you can build on and take control of your own care. Either one is the most effective by spending 15-20 minutes a day with them, as it requires repetition to learn the skills to regulate your body’s physiology.

Here is a link to the rest of my efforts that address a wide range of mental and physical disease states. It appears that most chronic diseases are caused by your body being exposed to sustained levels of stress chemicals and healing occurs in the presence of safety.

I need your help

The situation is getting much worse with bigger operations being performed with a higher complication rate. It should not be this way. It is the medical profession’s responsibility to listen, talk to you, and offer well-documented effective treatments. There is not one research paper in the last 60 years that has shown that a fusion works for back or neck pain compared to an organised rehab approach.

My efforts have helped many people individually, but the juggernaut of aggressive surgery is moving forward while non-operative resources are being eliminated. The only chance of slowing all of this down is from a grass roots effort. I am asking each of you to do what you can to share the message that chronic pain is solvable using research-based principles, which includes appropriate surgery. There is no data supporting spine surgery on normally ageing spines. Those of you suffering from failed spine surgery already know this all too well.

References

1. Chen, X et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166 – 173.
2. Perkins, FM and H Kehlet. “Chronic pain as an outcome of surgery: A Review of Predictive Factors.” Anesthesiology (2000); 93: 1123 – 1133.

The post Make the Right Decision About Spine Surgery – The Grid first appeared on Back in Control.

The post Make the Right Decision About Spine Surgery – The Grid appeared first on Back in Control.

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.

The post Prehab – Optimizing Surgical Outcomes first appeared on Back in Control.

The post Prehab – Optimizing Surgical Outcomes appeared first on Back in Control.

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.

The post It is Becoming Harder to Make a Living as a Surgeon……… first appeared on Back in Control.

The post It is Becoming Harder to Make a Living as a Surgeon……… appeared first on Back in Control.

After attempting many different approaches that failed, our team finally dug in our heels and wouldn’t consider elective surgery unless a patient would take responsibility for learning about pain and taking charge of his or her own care using a DOC-type structured approach. We wanted them to be engaged for at least eight weeks and preferably longer. My goal was to optimize the outcomes and avoid creating chronic pain. My surgical outcomes were better and my practice became more enjoyable and rewarding. What I didn’t expect was that dozens of patients with surgical problems began to cancel their scheduled operation because the pain had disappeared, even in the presence of bone spurs pinching nerves and causing severe sciatica. Here is one of those stories. This occurred about seven years ago. He still intermittently emails me and he never required surgery.

A pinched 5th lumbar nerve?

One afternoon, I received an anxious phone call from Jack, a 65 y/o retired businessman, asking me if I could see him urgently. His leg pain, which began two months earlier, was quite severe. As his pain pattern was so classic for a pattern for the 5^th lumbar nerve root (L5), and he was traveling, I put him on the surgical schedule. His MRI scan showed several bone spurs next to the L5 nerve, but none that were new. Although surgery was an option, I was a little uncomfortable, and wanted to give him a little time to calm down his nervous system. Much to my surprise, his pain quickly disappeared and I cancelled his surgery.

He experienced a second major flare-up about four months later. We both agreed that this time we would just get the problem definitively solved with surgery, and I put him back on the surgical schedule. By the time he saw me a week later for his pre-operative appointment, his pain again disappeared. This time we both felt that flared up pain circuits were were the cause. He wrote up his story, and we wanted to share it with you.

Jack’s story

When severe sciatic pain left me almost disabled 9 months ago, I knew it was time for back surgery…but the surgeon suggested I investigate an alternative to surgery; that my pain could be caused by a stressed nervous system. I was skeptical, but my research/practice of techniques eliminated my chronic pain…I am pain-free now. Details follow.

POSTPONE YOUR BACK SURGERY!

Yes, that’s correct…I’m humbly suggesting that you delay or postpone your back surgery until you’ve tried this alternative. I am grateful every day that I postponed my surgery…”dodged a bullet” as I think of it! Of course, I’m NOT a medical expert and I can’t adequately explain what happened to me; and your results may vary. But read my story, and see if you can benefit from this alternative to surgery.

Spontaneous onset

Here’s the background:  I’m a 65+ male, and have enjoyed excellent health my entire life; have jogged 3x per week since 1966 when Cooper first wrote Aerobics. About 18 months ago, I began noticing some mild sciatic pain…so I tried stretching…didn’t help. The pain level slowly increased, so my next “solution” was deep-tissue massage…maybe helped a little, but soon I was taking Tramadol, a mid-level pain reliever. Helped, but didn’t “fix” the problem. You know what comes next; right, I began Oxycodone. So in about 6 months, I had gone from healthy to being almost completely incapacitated with sciatic pain in my right leg. I could no longer jog. I realized it was time to consider back surgery!

Wait a minute

My primary care physician ccv referred me to Dr. David Hanscom, I now realized that the sciatic pain was caused by something seriously wrong with my lower back (a pinched or impinged nerve was my guess), and it seemed like surgery was necessary. By the time of the appointment, walking even with “help” from Oxycodone was painful. Dr. Hanscom and his team reviewed the imaging they had ordered (MRI and myelogram) and informed me that, yes, I had a “complicated” back! (Scoliosis, stenosis, pars defects, thin disks between the lower vertebrae, bone spurs, severe age degeneration). The surgery to correct this would be an L5-S1 fusion. But Dr. Hanscom also explained that none of these defects looked quite severe enough to be the convincing cause of my pain. So, while he would do the surgery if I insisted, he suggested I first look into other sources of my chronic pain. He gave me a copy of a book he wrote, Back in Control, and the link to his website, www.backincontrol.com.

I began reading the book when I returned to the hotel, and finished it that same evening! What a revelation! Chronic pain can be caused by mental stresses? Of course I was skeptical…I KNEW my pain couldn’t be caused by stress; I was retired, so what did I have to stress about? As the book explained, excessive stress and the chronic pain that results, are often not caused by external forces, but by internally generated issues. Could my sciatic pain be explained this way? It appears that this was the case.

Pain free

Over the following weeks, and now months  (8 months since my initial appointment with Dr. Hanscom), I’ve read and tried to follow the therapies prescribed by several additional books that have helped understand the cause of my pain…and the pain has been in total remission for about two months now. I’m even jogging again! Of course, there have been ebbs and flows of increased and decreased pain, but the trend is definitely decreasing. (I’m keeping a “pain journal” where I record a daily pain level, and activities that might impact the pain.)

Resources

Here are the other books I’ve found valuable:

1)     Unlearn Your Pain, by Howard Schubiner, MD

2)     Forgive For Good, by Fred Luskin, PhD

3)     The Hoffman Process, by Tim Laurence

4)     Healing Back Pain, by John Sarno, MD

5)     The Mindfulness Solution to Pain by Dr. Jackie Gardner-Nix

My hope is that this short history of my struggles with chronic pain will motivate potential back surgery patients to at least consider a self-directed structured approach as an alternative to surgery.

Jack

P.S. Why am I opposed to back/spine surgery?  As I understand it (a “civilian”, NOT a medical professional!) the complexity of the spinal area, the bone, muscle, and nerves, makes the outcome of spine surgery “iffy”. For many patients, the first surgery is “1 of __”.  In my case, I thought that simply decompressing the spur impinging the L5 nerve was the easy answer. But Dr. Hanscom explained that such a “simple” surgery could cause instability in other portions of the spine.

My initial position was,” I’m in pain, YOU fix it!”—a passive approach. The effective concept is that I CAN FIX THIS MYSELF!

Modern neuroscience 

We now know that although “stress” is linked to pain, the more accurate description would be that any mental or physical threat simulates the body to secrete hormones that increase your chances of survival and your whole body goes into a hyper-vigilant state. It is a necessary survival response. When these levels of stress chemical sustained, they wreak havoc with your body. There are many illnesses, symptoms and diseases that result, including early death. One of the effects is markedly increasing the speed of nerve conduction, so you will feel more pain. (2) As you learn the techniques to regulate your body’s chemistry, many symptoms resolve, including pain – even in the presence of “surgical” lesions.

Making your final decision about spine surgery will be outlined in my book, Do Really Need Spine Surgery? Take Control with Advice from a Surgeon.  All the factors affecting your choice are organized around a “Treatment Grid” to help you heal, with or without surgery. Make the correct choice.

1. Perkins, FM and H Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
2. Chen X, et al. Stress enhances muscle nociceptor activity in the rat. Neuroscience (2011); 185: 166-173.

The post Structural Sciatica Resolved Without Surgery first appeared on Back in Control.

The post Structural Sciatica Resolved Without Surgery appeared first on Back in Control.

Roy Carey, a well respected spinal surgeon in Melbourne created this video highlighting the decision-making about undergoing spine surgery. It helped reduce the frequency of spinal surgery in Victoria, New Zealand.

The post Think Twice About Spinal Surgery first appeared on Back in Control.

The post Think Twice About Spinal Surgery appeared first on Back in Control.