You can’t fix what you can’t see (or isn’t there)
I am publishing my book, Do You Really Need Spine Surgery: Take Control with Advice from a Spine Surgeon, this fall of 2019. I retired from my practice as a complex spine surgeon in December of 2018 to pursue this project.
The 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 is problematic. 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 random “non-care.” (1) 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.” (2)
- 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. (3)
- The success rate of performing a fusion for LBP is less than 30%. (4,5) 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.
Chronic pain is a complex problem (7) that requires time and a multi-pronged approach. Current neuroscience research has unlocked the puzzle of chronic pain and it’s a solvable problem using the correct paradigm. In the current medical climate, physicians are being asked (and pushed) to move too quickly, and not factor in all of the variables that affect pain and surgical outcomes. One 2014 research paper reported that only 10% of orthopedic spine surgeons and neurosurgeons are addressing and treating the well-documented variables that predict and create poor outcomes. (8) For example, one common problem is lack of sleep. A large four-year study out of Israel demonstrated that insomnia INDUCES low back pain and they did not find the reverse causation where LBP caused lack of sleep. (9) If a volunteer is sleep-deprived for just one night, his or her pain tolerance drops dramatically. (10)
I am publishing my new book, Do You Really Need Spine Surgery? with mixed feelings. I am excited about the way it is evolving, but disturbed by the fact that it is so needed in this modern era. We already have the knowledge and technology to offer superb care and much of the data is being ignored. (8)
The treatment grid
My intention is to educate you and your primary care physician 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
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. As mentioned above, proceeding with low-odds surgery in the presence of untreated chronic pain has a high chance of making you worse – much worse. I witnessed this scenario weekly.
Conversely, if you have an anatomical abnormality that might respond to surgery, calming down your nervous system puts the odds much more in your favor for a good resolution of your pain.
Spine surgery is out of control. I am not against surgery and I was a complex spinal surgeon for 32 years. From the beginning, I felt that too much surgery was being performed. For almost eight years 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. (4)
Over the last five years, I have witnessed patients undergoing increasingly major surgeries for less clear indications. Often their spines were completely normal for their age. What became intolerable for me was frequently seeing the severe downside of a failed operation. Any spine surgery creates permanent damage to the spinal column and the bigger the operation, the worse the potential downstream problems. Many patients will tell you that undergoing spine surgery was one of the worst decisions of their life. “If I just knew how bad this could be, I never would have done it.” As our non-operative approach became more effective, my rate of performing elective surgery dropped down to 4.6%.
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. Video: Get it Right the First Time
- 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.
- Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 1904.
- Ballantyne J, et al. Chronic pain after surgery or injury. IASP (2011); 19: 1-5.
- Baliki MN, et al. “Nociception, pain, negative moods and behavior selection.” Neuron (2015); 87: 474-490.
- Young AK, et al. Assessment of presurgical psychological screeningin patients undergoing spine surgery. Spinal Disorders Tech (2014); 27: 76-79.
- Agmon M andGalit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
- Krause AJ, et al. The pain of sleep loss: A brain characterization in humans. J.Neurosci 2019; 10.1523/JNEUROSCI.2408-18.2018.