Health care professionals want to provide healing. When we don’t have the tools to help you, all parties become incredibly frustrated. Additionally, the most basic healing modality is feeling safe with your provider because it creates a shift in your physiology to one of safety or “rest and digest. This is where healing occurs, and we are limited by the business of medicine that won’t let us spend time with our patients. How can we know you? What is your life like? Are you feeling stressed? How can we methodically understand your care up to this point, and make thoughtful decisions about what to do next? What has been done to optimize your chances of a good outcome of surgery?

Modern medicine is evolving in a dangerous direction with regards to your care. The major factor in deciding to offer a procedure or treatment is often whether it’s covered by insurance and how well it is reimbursed. The effectiveness of the intervention is a lesser consideration. In fact, we are sometimes encouraged to perform surgeries that have been documented to be ineffective. Additionally, there is little accountability for the outcomes unless there is severe negligence.

Profits over quality

The business of medicine, like any other business, is focused on making a profit. There are computer programs that monitor physicians’ contribution to the profit margin. The most revenue comes from performing procedures, many of which have been documented to be ineffective.¹ The downside risks include unnecessary costs, significant risks and patients are often worse off than before the intervention.² It has also been documented that only about 10% of spine surgeons are addressing the known risk factors for poor surgical outcomes.³

Dr. Ian Harris, who is an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo, where he extensively documents the data behind many procedures for pain that have been proven to be of no benefit and it hasn’t stopped their use.⁴

We want to provide relief, it is what we are trained to do, but we are not aware of the alternatives. It is like trying to hit a major league baseball pitch with a golf club. I would have no insights either unless I hadn’t suffered with chronic pain for over 15 years.

What works?

There are many ways to cause your body to change from threat physiology to safety. A term for this is, “dynamic healing.” Input (your stresses) are processed in a manner that has less impact on your nervous system, the nervous system can be calmed down, and there are ways to directly stimulate the powerful anti-inflammatory effects of the vagus nerve.

Effective treatments are often not covered or don’t generate enough revenue. For example, expressive writing has be shown to been helpful in multiple medical conditions in over 1,000 research papers.(5) Yet, I had never heard of it until I accidentally ran across it in 2003. It costs nothing, has minimal risk, and is rarely presented as a treatment option. It has proven to decrease symptoms of asthma, depression, and rheumatoid arthritis, improve student’s athletic and academic performance, speed up wound healing, and diminish many other symptoms. I had dinner with one of the pioneers of the technique, James Pennebaker, who is a psychologist from Austin, TX. The methods may differ, but it has only been reinforced as an effective tool. There is a lot of debate of why it works, but not about whether it works.

Mindfulness-based stress reduction has also been demonstrated to decrease pain in many papers and is usually not covered by insurance. I watched several excellent pain programs in the Puget Sound shut down because they could not afford to keep them open.

Listening is a proven healing modality in addition to being a basic requirement to understand a given patient’s whole situation. Dr. Francis Peabody, a famous Boston physician, was concerned about the intrusion of technology into the patient-physician relationship. One of his more notable quotes was, “The secret of care is caring for the patient.” He wrote this in 1927 when he was concerned about the intrusion of technology into the patient doctor relationship.(6)

What about the patient?

A person suffering from chronic pain is trapped beyond words. My term for it is, “The Abyss.” These are just a few of the ways.

• You have told that there is nothing wrong and you have to live with your pain the best you can. The reality is that there is a physiological explanation for all of it.
• There does not seem to be way out. Most people lose hope. The solutions are there but not being offered. The patients who break out of it feel the healing process is “disturbingly simple.”
• You are labeled by almost everyone, including the medical profession. They include, drug seeker, malingerer, lazy, not motivated, making things up, not tough enough, and the list is endless.

When you are trapped by pain, your frustration and anger is deep and powerful. This scenario creates a more intense flight or fight response, the blood supply to your brain shifts from the thinking center to the survival midbrain, and your behaviors are not rational.

Another problem that is not often acknowledged is that of inducing a depression from repeatedly dashing people’s hopes. This was powerfully demonstrated by Harry Harlow.⁶

Inducing depression–“The Pit of Despair”

Harry Harlow was an internationally renowned psychologist who pioneered research in human maternal-infant bonding using primates. During the first half of the 20^thcentury, it was felt that mothers should touch their children as little as possible. Leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media. Interestingly, or tragically enough, their recommendations were based on rodent research.  Dr. Harlow was the leading force in changing the tide of opinion using various species of monkeys. His story is well-presented in an entertaining book, Love at Goon Park by Deborah Blum. (

In the 1960s, he turned his attention, also based on primate research, to some of the smaller details of human interaction.  He wanted to understand how to induce depression. He used isolation methods and ways of simulating parental neglect or even abuse. He was able to create seriously disturbed monkeys, but not depressed ones.

He finally found a consistent methodology by devising an apparatus that resembled an upside-down pyramid. The sides were steep, but still allowed the monkey to climb to the top to peek outside the mesh-covered top. For the first couple of days, the monkeys would repeatedly climb up to look out and quickly slide back down. Within a couple of days, they would give up, sit in the middle of the device, and not move. They became almost unresponsive, and when they returned to their families, they wouldn’t revert back to normal social behavior. It didn’t matter what problems the monkey had prior to the experiment. The abnormal monkeys became worse and normal monkeys suffered the same fate. Even the “best” monkeys from stimulating and interactive families would succumb. The researchers were upset and called the apparatus, “The Pit of Despair”. It was felt that this “learned helplessness” was from a combination of feeling the loss of a good life reinforced by occasional glimpses of the outside world and feeling trapped. Within a half a week, every monkey spiraled down.

Tulsa

The surgeon was doing what he was trained to do with the best of intentions. I would feel badly during the first eight years of my career if I could not find a way to relieve my patients’ pain with surgery. The patient was trapped at a level that is indescribable and surgery is often viewed as the definitive answer. It also requires enduring more pain and a lot of anxiety about the whole process. So, the level of disappointment is even higher when it fails.

The literature also shows that pain is often worsened when surgery is performed in the presence of untreated chronic pain.² I was also not aware of that data until after I had quit my surgical practice. For him to act out the way he did is unacceptable but understandable. BTW, suicide is problematic in patients suffering from relentless pain. I was also at that point towards the end.

Recap

Physical therapy, chiropractic adjustments, injections, acupuncture, vocational retraining, medications, traction, inversion tables, and finally surgery. How many times can your expectations be dashed before you lose hope? You cannot blame a person for actions taken in this state of mind.

All the parties were victims of the business of medicine and I put the blame squarely on its shoulders. There are many variables, but the energy is all directed the same direction–money.

The business of medicine has trapped both the providers and patients and with computerized medical records, it is getting steadily worse. There are real solutions, but both the medical profession and patients are going to have to demand it.

References

1. Jonas, JB, et al. Are invasive procedures effective for chronic pain? A systematic review. Pain Medicine (2019); 20: 1281-1293.
2. Perkins, FM, and Henrik Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
3. Young AK, et al. Assessment of presurgical psychological screening in patients undergoing spine surgery. Journal Spinal Disorders Tech (2014); 27: 76-79.
4. Harris, Ian. Surgery, The Ultimate Placebo. New South Publishing, Sydney, Australia, 2016.
5. Pennebaker JW and JM Smyth. Opening up by Writing it Down. 3^rd edition. Guilford Press, New York, NY, 2016.
6. Peabody, FW. The Care of the Patient. NEJM (1927); 88:877-882.
7. Blum, Deborah. Love at Goon Park. Perseus Publishing, New York, NY, 2002.

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A patient’s story – spine surgery gone bad

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

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

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

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

My perspective

I am going simply list the issues in this situation.

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

Do You Really Need Spine Surgery?

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

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

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

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

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

Be careful

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

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

There is still hope

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

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

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

Questions for your surgeon

References

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

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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.

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