My Early Surgical Philosophy

I started my practice in Seattle in 1986.  I was feeling pretty beat up from my spine training. I felt well-trained and still had a rather high opinion of myself,  but I was tired.  It also quickly became clear that low back pain was much more complicated than I had thought.  Patients with low back pain made up the majority of my practice.  I also had no insight into the nature of chronic pain, no clue to its devastating effects.

I had joined the most prominent group in town. I was the fourth spine surgeon. We were all determined to create a major spine center in Seattle.  I worked very long hours.  I approached the whole process with a very high level of energy.  It was also an era where we had just started using screws directly into the vertebrae to immobilize them.  This technique offered a higher chance of obtaining a solid fusion.  I was enthusiastic about my ability to obtain a successful fusion.  If someone had back pain for more than six months, I would order a discogram.  It is a test where dye is injected into the disc under x-ray control.  If the injection simulates the patient’s usual pain, it is considered a positive test.  Based on that test, I would then offer my patients a fusion.  I was quite diligent trying all types of non-operative care during this time.  I had quite a lot of success avoiding surgery by aggressively immobilizing the spine with a semi-rigid brace for three or four months.  Nonetheless, I performed a lot of spine fusions for low back pain.  I felt bad if I couldn’t offer my patient a fusion. Some patients would do extremely well.  However, many if not most, would have some improvement in pain but still remain disabled.  It was not clear to me what variables would predict a good outcome.

One evening in the fall of 1987, I heard a knock on my door.  A gentleman by the name of Stan Herring introduced himself.  He said he was a physiatrist who specialized in spine care and would like to have me work with him as his surgeon.  He had to explain to me that a physiatrist is a rehabilitation physician.  The philosophy is to take whatever physical limitations that exist and maximize the patients’ function.  I had not heard of this concept before and it sounded very interesting.  I began to spend a half a day a week in his office.  It quickly became clear that this was a different world of spine care than I had been exposed to.  He knew which physical therapists he wanted to work with.  He knew what they did and why.  He worked with a pain psychologist.  His office practiced a much more complete approach to the pain problem.  When his patients required surgery, the results were consistently better.  My role in this practice became that of talking patients out of surgery.  Once I explained in detail the magnitude of the surgery, they would usually proceed with their rehab.  Most patients seemed to do well without the surgery.  I became better at selecting my patients for low back pain surgery but was still frustrated by the unpredictability of the outcomes.  It was not until 1993, seven years into my practice, that I stopped performing fusions for low back pain.  I am one of the few surgeons who has aggressively been on both sides of this fence of using surgery as a solution for non-specific low back pain.