Jean was a 48 year-old woman who came to me from a neighboring state for a second opinion. She filled out an extensive spine pain questionnaire, which included many questions about her quality of life, in addition to a history and diagram of the pain.
She was a healthy physically active rancher. Her low back pain started in the summer of 2005 after a lifting injury. The pain had become constant and was located throughout most of her back. She was still functioning at a fairly high level, in spite of the pain.
Her prior care
Jean’s care so far had consisted of six visits to physical therapy, and two sets of cortisone injections in her back, none of which had been helpful. She had not been prescribed a ongoing organized treatment plan. On her second visit to a spine surgeon, it was recommended that she undergo a eight-level fusion of her lower back from her 10ththoracic vertebra to the pelvis. It is a six to eight-hour operation that carries significant risks.
Jean’s x-rays showed that she had a mild curvature of her lower back. Other imaging tests did not reveal any identifiable, structural source of pain. From my perspective as a scoliosis surgeon, I felt her spine was essentially normal for her age.
Instead, I felt that her pain was probably from the muscles and ligaments around the spine. The medical term that we use is myofascial. When an operation geared towards the bones, such a fusion, is done in the presence of mostly soft tissue pain, it rarely works. In addition to the risks, the entire lower back becomes a solid piece of metal and bone. This surgery should only be done if there are no other options. The procedure comes with long-term lifestyle limitations and she was still so active.
At this point, I was perplexed as to why surgery had been recommended when she had done so little rehabilitation. I also didn’t understand why she was continuing to experience such severe ongoing back pain without any obvious cause.
What was missing?
I consulted her spine intake questionnaire to look for clues.
It revealed that she’d had some marital difficulties and had just reconciled with her husband six months earlier. That immediately caught my attention because marital troubles usually indicate significant stress. She then said her job had become much more difficult. Although she worked for the same employer, they had forced her to switch duties without adequate training. She was worried about not only her performance, but also her ability to keep her job – another major problem.
I turned the page. A month before her pain began, her twenty-six-year old son had drowned. I knew that outside stressors played a role in chronic pain, but this factor had never been so powerfully demonstrated. Her case really brought home for me how crucial it was to take a full view of the patient’s life and circumstances, instead of just looking at surgical solutions.
As I sat there stunned, I realized that I needed to do something different. In fact, the whole medical profession needed to do something different. How could a surgeon have recommended a fusion without taking the time to get to know Jean and to hear her circumstances?
From that moment, some form of structured rehabilitation became my focus with every patient, without exception. I have not taken my eyes off of that vision since that day.