Do You Really Need Spine Surgery? Take Control with Advice from a Surgeon considers all factors affecting your perception of pain and organizes them into a treatment grid that allows you to make a good decision regarding having spine surgery.
Spine surgery is out of control. I am not against surgery and I was a complex spinal surgeon for 32 years. From the beginning of my career, I felt that too much surgery was being performed. But for my first eight years of practice, I was a part of this aggressive approach. When a research paper came out in 1993 showing the return-to-work rate was only 22% after a low back fusion for pain, I immediately stopped performing that operation. (1)
But he rate of spine surgery has continued to rise in spite of evidence that much of it is ineffective. It rose rapidly in the mid-1990’s with the introduction of new techniques that did improve the fusion rate. However, outcomes haven’t improved, and disability keeps rising. Why?
“Let’s try spine surgery”
Spine surgery works wonderfully well when there is a distinct identifiable anatomical abnormality, and the symptoms are in the expected region of the body. However, it works poorly if surgery is done for “pain” and the source of it is unclear. There is a widespread belief among patients and many physicians that if everything else has been tried and failed, then surgery is the next logical step. Nothing could be further from the truth.
Defining the correct anatomical problem to surgically treat would seem to be the first logical step. However, this step is often not done well. One of the most glaring examples of blindly proceeding with surgery in spite of the evidence stacked against it, is performing a fusion for low back pain. There was one paper in 2001 that hinted it might be effective, but it was sponsored by a spinal instrumentation company, and the non-operative care was not defined. (2) One well-known paper compared lumbar fusions for pain to a solid rehab protocol and the non-operative care resulted in better outcomes. The final comment in the paper was that “this type of care wasn’t widely available.” (3)
- It is well-documented that disc degeneration, bone spurs, arthritis, bulging discs, etc. are rarely the cause of back pain. So, when a fusion is performed for LBP, we really don’t know from where it might be arising. (4)
- The success rate of performing a fusion for LBP is less than 30%. (5) Most people expect a much better outcome and the resultant disappointment is also problematic.
- If any procedure is performed in a person with untreated chronic pain in any part of the body, he or she may experience chronic pain at the new surgical site up to 40-60% of the time. Five to ten percent of the time it is permanent. (6)
Trip to the dentist
Consider going to the dentist with a painful cavity that may require a root canal, crown or extraction. There is a defined problem, and the pain will predictably disappear once the problem is solved. But what about the situation where you might be having severe mouth or jaw pain, and there isn’t a tooth that seems to be the source. Would you expect your dentist to randomly try working on different teeth to see how it might work? After all, these are minor interventions compared to undergoing spine surgery. What if the problem is gum disease, a sinus infection, TMJ, or even a tumor in your oral cavity? Making an accurate diagnosis of the problem is always the first step in solving it.
The treatment grid
My intention is to educate you and anyone on your health care team about all of the issues that factor into deciding whether to undergo spine surgery. There are two sets of variables: 1) the type of anatomy – can you see it on a diagnostic test? 2) The status of your nervous system and resultant body chemistry. Are you calm? Or are you stressed and hyper-vigilant? If your nervous system is on “high alert” for any reason, the outcomes of surgery are predictably poor, especially if you can’t identify the anatomical problem. The combinations result in four possible scenarios. The book is based around this treatment grid:
- IA—Structural lesion, calm nervous system
- IB—Structural lesion, stressed
- IIA—Non-structural lesion, calm
- IIB—Non-structural lesion, stressed
The Treatment Grid
You will be able to place yourself in the correct quadrant with the help of your providers. Each one has a distinct treatment approach, which will allow you to make better treatment choices. The most basic decision is that if there isn’t a clearly identifiable source of pain, then surgery isn’t an option, regardless of how much pain you are experiencing. Low-odds surgery in the presence of untreated chronic pain has a high chance of making you worse – much worse. Especially if the surgery doesn’t go well.
Mike was in his mid-40’s and had just moved to Seattle about six months earlier. He was undergoing some physical testing to qualify for a government job. During the process, he tripped and twisted his back. His back pain was severe with a lot of muscle spasms. About four months after the fall, a surgeon elected to perform a fusion at his lowest level of his spine (Lumbar 5-Sacral 1). He had a small bony defect called a spondylolisthesis that had been there his whole life and was unlikely to be the source of his acute back pain. There was no reason to consider surgery.
During the operation, one of the screws used to stabilize his spine was misplaced and impaled the 5th lumbar nerve root. It was removed a couple of days later, but the damage had been done. When he saw me for another opinion about a year later, he was still experiencing severe pain down the side of his right leg. He had no leg pain before the surgery. He was on high-dose narcotics without relief. He had already figured out that the surgery was unnecessary and was really angry about it. His life as he had known it was gone – permanently. There was nothing that I could do, I heard a couple of years later that he had undergone yet more surgery without any relief.
This book will enable you to understand the difference between a spine problem that is amenable to surgery versus one that is not. It covers the whole spine from your neck to your pelvis. You will also be able to assess the state of your nervous system and resultant body chemistry. If you are stressed, there are simple, consistently effective measures that can calm your nervous system. The goal of the comprehensive treatment process is to help you become pain free with or without surgery.
Whatever you decide to do or what resources you might use, don’t jump into spine surgery until you understand the whole picture. It may be the most major decision of your life.
- Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 1904.
- Fritzell P, et al. “Swedish Lumbar Spine Study Group. Lumbar fusion versus non-surgical treatment for LBP.” Spine (2001); 26: 2521-2532.
- Brox J, et al. Randomized Clinical Trial of Lumbar Instrumented Fusion Cognitive Intervention and Exercises in Patients with Chronic Low Back Pain and Disc Degeneration. Spine2003; 17: 1913-1921.
- Boden SD, et al. “Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.” J Bone Joint Surg (1990); 72:403– 8.
- Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diagnosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
- Ballantyne J, et al. Chronic pain after surgery or injury. IASP (2011); 19: 1-5.
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