I had joined a prominent orthopedic group in town and was the fourth spine surgeon. We were all determined to create a major spine center in Seattle. I worked long hours with a high level of energy.  It was also an era where we had just started placing screws directly into the vertebrae to immobilize them. This technique offered a higher chance of obtaining a solid fusion. I was enthusiastic about my ability to obtain a solid fusion. If someone had back pain for more than six months, I would order a discogram, which is a test where dye is injected into the disc under x-ray control. If the injection simulates the patient’s usual pain, it is considered a positive test. Based on that test, I would then offer them a fusion that would remove the pain generator.

I was also quite diligent trying all types of non-operative care during this time. One approach I used was aggressively immobilizing the spine with a semi-rigid brace for three or four months while simultaneously work on conditioning in the gym. The idea was that if a fusion was going to work, why not try something to immobilize the spine that is less invasive. I had a lot of success with the bracing. Nonetheless, I performed many spine fusions for low back pain and I thought that the success rate would be over 90%. It is a big operation. I felt bad if I couldn’t offer my patient a fusion. Some patients would do extremely well. However, many if not most, would have some improvement in pain but still remain disabled. It wasn’t clear to me what variables would predict a good outcome.

One evening in the fall of 1987, I heard a knock on my door. A gentleman by the name of Stan Herring introduced himself.  He said he was a physiatrist who specialized in spine care and would like to have me work with him as his surgeon. He had to explain to me that a physiatrist is a rehabilitation physician. The philosophy is to take whatever physical limitations that exist and maximize the patients’ function. I had not heard of this concept before and it sounded interesting.

I began to spend a half a day a week in his office. It quickly became clear that this was a different world of spine care than I had been exposed to. He knew which physical therapists he wanted to work with, and knew what they did and why. He worked with a pain psychologist. His office practiced a much more complete approach to the pain problem. When his patients required surgery, the results were consistently better. My role in this practice became that of talking many patients out of surgery until they had really engaged in the rehab process. Once I explained the magnitude of the surgery in detail, they would usually proceed with their rehab and most patients seemed to do well without the surgery.

I became better at selecting my patients for low back pain surgery but was still frustrated by the unpredictability of the outcomes. It was not until 1994, eight years into my practice, that I stopped performing fusions for low back pain. The data out of Washington Workers Comp showed that the return to work rate one year after surgery was only 15%. It was half the rate of those who had not undergone surgery. (1) Meanwhile, I descended into my own ordeal with chronic pain and I didn’t emerge from it for over 13 years. Slowly, the current DOC process evolved about ten years later. It took me a long time to figure out what was going on and now the last five years of neuroscience research has revealed the answers to solving chronic pain. Surgery is occasionally needed but is never the definitive answer in isolation. It is also never indicated for chronic LBP and degenerative disc disease.

I am one of the few spine surgeons who has aggressively been on both sides of this fence of using surgery as a solution for non-specific low back pain and now successfully helping patients heal without the risk of an operation. It has been quite a journey.

1. Franklin GM, et al. Outcome of lumbar fusion in Washington State Workers’ Compensation. Spine (1994); 19:1897–1903.

The post My Early Surgical Philosophy first appeared on Back in Control.

The post My Early Surgical Philosophy appeared first on Back in Control.

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.

No one thinks that a surgical complication will happen to them. During my spine fellowship, I witnessed a large number of major complications and I was sure that I was going to be better than them – even though they were considered some of the top spine surgeons in the world. I set out on a quest to go without any complications for a year. I did not give up easily, but of course I failed. There is an inherent risk of any surgery with it rising with the complexity of the case. For example, there is a trend in the United States to perform multiple-level fusions, sometimes the length of the spine. The complication rate in adults is high and a significant percent of them are devastating – catastrophic. (1) Over 32 years of performing complex spine surgery, I watched hundreds of patients, including my own, have poor outcomes – sometimes from a direct technical problem in surgery and often from medical problems that can occur from prolonged operative time and blood loss. Even without a complication the pain may persist or worsen. (2)

Do You Really Need Spine Surgery?

The purpose of this article is to admonish you to consider if you really need the surgery and will the benefits outweigh the risks?  Every day in clinic I had several patients tell me that if they had just understood how much worse off they could be after surgery, they never would have undergone the procedure. Most of the time the surgery went well but their pain was worse. Add in a complication and the resulting situation was often intolerable.

What is making the current surgical environment harder for me to deal with is that we witnessed hundreds of patients go to pain free by systematically implementing medically treatments with minimal risks. Back in Control,  provided a framework that organized the patients thinking and most of it was implemented on their own. We now have The DOC Journey, which reflects the successes of many patients. The key is you taking charge of your own care once you understand the nature of chronic pain. One of he worst parts of this scenario is that many of the patients who got stuck in this hole of a failed back surgery, had a normal spine for their age. Surgery should not have ever been offered to them since you can’t fix what isn’t broken.

A life changing complication

I remember the moment my surgical life changed many years ago. I was in clinic about 11 o’clock in the morning when the ICU nurse called me and told me that my patient I had done surgery on yesterday couldn’t see. I had seen him earlier on rounds and he seemed fine. I rushed over to the unit and he was completely blind. He told me that he thought someone had placed a cloth over his eyes as part of his post-operative care. We had done an eight-level fusion on him for what we call, “flatback.” He had lost the curvature of his lower back from degeneration of his discs and he was tilted forward. He was experiencing a lot of pain.

The surgery had gone well and my colleague and I complemented each other on how well it went. However, one of the risks of any spine surgery in the face- down position is the blood supply to the eyes. For reasons that are unclear the flow was compromised and the nerves to his eyes were damaged. He never regained any of his vision. Needless to say, everyone was devastated. The only inspiring part of the situation was his attitude. He walked into my office about three months later and said, “This is the deck of cards life has dealt me and I am going to play it.”

He returned to see me about ten years later to have some of the hardware removed that was prominent. I was learning more about chronic pain and the effect that stress has on the body’s chemistry and perception of pain. I talked to him for a while and found out that just prior to his surgery, he was under extreme marital and family stress that eventually culminated in a divorce. I was so convinced that surgery was the answer that I did not pick up on it. I was not aware at the time how stress translates into changes in the body’s chemistry, which creates many different symptoms. what a critical factor

Didn’t need it

Today, in my practice, he wouldn’t have been a candidate for surgery. His flatback was not as severe as many I have seen rehab successfully without surgery. I would have had physical therapy stretch out his hips and get him into the gym. His sleep and stress would have been addressed and he would have done well. As I didn’t know how successful a structured approach could be, I did not offer these options to him. I would have certainly waited until his life stresses calmed down. He is blind from an operation that could and should have been avoided.

“If I Were Your Spine Surgeon”

Please read this book, Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice. Within a couple of hours you will understand the reasoning behind the decision to undergo a spine operation or not. There are two factors to consider; 1) Is there a structural abnormality that is amenable to surgery? 2) Is your nervous system in a calm or hypervigilant state? You will be able to place yourself into one of four quadrants with each one have a specific treatment approach. Watching many patients having their normally aging spines destroyed by ill-advised surgery is what caused me to quit my practice to pursue bringing proven effective treatments into the public domain. There are thousands of research papers documenting what should be done to treat chronic mental and physical pain that is not being widely implemented. Sustained levels of inflammatory markers are the hallmark of chronic disease. Surgery for inflammation cannot and does not work. There is not one paper in the last 60 years that shows that fusing someone’s spine for pain works.

It appears to me that many people put more effort in buying a car than they do making a decision about undergoing spine surgery. Although they are informed of the potential complications, there is no way to comprehend how bad life can be trying to live with a failed spine surgery. You are the one with the pain. No one else can accurately make the final decision whether the pain you are experiencing is worth the risk. Video: Get it Right the First Time

Anxiety

BTW, is the pain you are trying to solve your mental or physical pain? Please read this post I wrote, “Am I operating on your pain or your anxiety?” Anxiety does respond to the treatments outlined in The DOC Journey. As the anxiety drops, nerve conduction slows down and your pain drops. (3) Surgery will not solve anxiety even if the operation relieves your physical pain.

Don’t play roulette with your life. There is no turning back on this decision and there is no need to gamble. Once you understand the issues, you can make the correct choice for you.

1. Cho SK, Bridwell KH, Lenke LG, Yi JS, Pahys JM, Zebala LP, Kang MM, Cho W, Baldus CR. Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2- to 7-year follow-up. Spine (Phila Pa 1976). 2012 ;37(6):489–500
2. Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
3. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166-173.

The post Comprehending the Downside of Spine Surgery first appeared on Back in Control.

The post Comprehending the Downside of Spine Surgery appeared first on Back in Control.

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.

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