The first phase of the DOCC Project is to consider whether the source of your back pain is structural or non-structural. To figure this out, work in concert with your doctor. Chapter Nine: “Do You Need Surgery”? provides you with enough information so you can engage in an in-depth conversation about your specific anatomical problem. In spite my emphasis on non-operative care, I am a surgeon. It is my responsibility to diagnose and clearly explain to you what kind of structural problem there might be.
There are two reasons to make a clear diagnosis the highest priority. First, you cannot rehabilitate a painful structural problem. If the pain is severe enough, it needs to be fixed. Second, if you don’t have a structural problem, you have to be assured that you don’t have a structural problem, because your anxiety will remain high if you are worried about something being missed.
Once you’ve labeled your problem as structural or non-structural, you can decide on surgery. Structural problems typically require surgery; non-structural do not. This decision needs to be made, and very clear in your mind, before you start the DOCC Project. As long as any question exists for you, it will be difficult if not impossible to be fully committed.
If a patient’s problem is structural and significant, then I will move ahead with surgery relatively quickly and implement the DOCC Project later. If the problem is structural but not severe, then we may attempt rehab to see if there’s enough of an improvement to avoid surgery.
If the problem is NOT structural, then the only other possible source of the pain is an injury to the soft tissues around the spine. This is the most important distinction I make as an orthopedic surgeon. With non-structural issues, I do not recommend surgery under any circumstances. I spend a significant percentage of my practice not only telling my patients that they don’t need surgery, but also explaining why they don’t need it. This is a critical part of my job. It also clarifies the situation for the rehab doctors I work with so the whole team can move forward.
If one of my patients needs to hear this message from someone else, I strongly encourage that he or she get a second opinion. If I feel the second opinion is way off, I don’t hesitate to call the other surgeon and ask for clarification. If a case is controversial, I’ll also present it to colleagues for feedback.
Remember that by virtue of having lived in misery with pain for so long, you’ll be vulnerable to a surgeon walking into a room and saying, “I can take care of you with surgery.” Additionally, surgery is viewed by almost everyone as “definitive.” How can you turn it down? However, you may be undergoing an operation that is not only unnecessary but also potentially damaging. It can negatively affect your quality of life, permanently. Do not trust anyone, including me, to tell you what to do. Research your problem with a vengeance so that you fully understand your situation. In the last four chapters of this book, I provide some additional information to help in this effort.
It can be difficult for patients to accept that their problem is, essentially, “undetectable.” They are in so much pain; it seems impossible that so many tests would come up negative.
Trust me on this one. Every surgeon I know is anxious not to miss a structural problem. Surgeons probably over-test our patients looking for a source of pain. We practically beg for a problem we can fix. We love to fix things. When this happens, you are happy and we are happy. If your surgeon is telling you that there is no structural problem, chances are there isn’t one.
If there is a structural problem, decide to surgically deal with it or not. If it’s a soft tissue problem, it’s important to accept it and move forward. If you don’t, the ongoing anxiety over the source of your pain will hold you back from progressing forward.