When the DOC project began to evolve in 1999 it was my feeling that if there was a structural problem that it first needed to be dealt with surgically and then we could move ahead with the rest of the protocols. I define a structural problem as one that can be identified on an imaging study and the symptoms closely match. You have to see the problem before you can fix it. My reasoning was that you couldn’t concentrate enough while in pain to internalize the process. After all, you can’t rehab an infected tooth. I was wrong on several counts
In spite of my advice to proceed with surgery, some patients, even with significant pain from a distinct identifiable problem, wanted to wait and try the non-operative structured care first. Many would return for what I thought would be the visit to make a final surgical decision and their pain would be minimal or gone. We never did the operation. The idea that calming the nervous system could diminish pain arising from a structural problem was a major shift in my thinking. I now have over 100 patients with surgical problems cancel surgery because the pain disappeared. The DOC process has significantly impacted my surgical practice.
Then I ran across several papers that pointed out that if you perform surgery in face of untreated chronic pain, that you can induce pain at the new surgical site up to 50% of time (pain lasting for up to a year) and 5-10% of the time it was permanent. (1) In other words, if you had a hernia repair while suffering from chronic neck pain, the hernia site could become chronically painful. It’s usually an almost painless procedure. The chronic pain areas of the brain are already on overdrive and you’re now plugging in different body parts. It explained many of the surgical failures I have witnessed over the years in spite of a technically well-performed procedure.
More predictable outcomes
It then became clear that the patients who actively engaged in learning about pain and using the tools of the DOC project had much less pain post op, ambulated more quickly, and predictably would have a better outcome. Around 2013 our team agreed that we would only perform surgery on a patient who was willing to calm down his or her nervous system for at least eight weeks before elective surgery. Some patients simply didn’t want to have any part of taking charge of their own care and went elsewhere. The patients who committed to themselves predictably did well.
I first met Ron about four months ago. He was in his late 50’s and just plain angry. At the first mention of doing some reading about pain he exploded. He wasn’t going to have anything to do with it. I hung in there and explained that he was certainly welcome to have someone else perform the two-level laminectomy and one-level fusion in his lower back. But it would not be me. I was certain he wouldn’t be returning.
He did return and over the next three months he underwent a remarkable transformation with much less LBP and improvement in his mood. As his leg pain persisted he underwent the surgery – and went home on the second post-op day almost pain free. He is muscular, and it was a fairly significant operation. The normal time in the hospital is four or five days.
“I got to know you”
I was talking to him at his discharge and reminiscing about the first couple of times I had met him. I said, “I think that your engagement in structured care concepts was really helpful and I am impressed at your enthusiasm at embracing them.” He agreed that it was the correct choice to wait. Suddenly he stopped the conversation, looked at me and said, “I got to know you.”
There’s a lot of pressure to “be productive” in medicine. There are endless conversations about how to maximize the surgical yield of the clinic. Often surgeons require updated scans to be done before they will even see the patient. If there is a problem that is amenable to surgery, then the decision to proceed is frequently made on the first visit.
With few exceptions I will no longer make a surgical decision on the initial visit. Why? It is critical to know the context in which the decision is being made. What kind of stress are you under? Is your pain severe enough to undergo any procedure? Do you really know the risks? We don’t even know each other, and we are about to become partners in a risky venture.
Impact of stress
Some of the insights that have surfaced on the second or third visit are:
- “My son just died two months ago in a car accident.”
- “My husband retired, and we are driving each other crazy.”
- “I lost my daughter to breast cancer last week.”
- “I have a drinking problem.”
- “I lost my job”
These severe stressors impact both the perception of pain and also the decision-making process. Do you feel comfortable discussing these details with a doctor you have just met? It’s a bad idea to make major decisions when your life has been impacted to this degree.
Knowing my patients allows me to teach them strategies that enable them to both decrease pain and cope with stress. Spine surgery is a significant stress. I also enjoy them.
Don’t make a major decision about surgery on your first visit. Would you buy a house or used car without an inspection? Why would you allow someone (including me) you have heard “has a great reputation” decide your fate in under an hour? The risks of spine surgery are too high, and the potential downside can be catastrophic.
Know your surgeon – before surgery. More importantly, make sure he or she knows you.