When is Spine Surgery Appropriate?
By Dan Robbins, MD
Fellowship-trained spine surgeon
The thought of having any surgical procedure fills most people with a sense of fear and dread. This is especially true of surgery on the spine. A torrent of “what ifs” will immediately flow through ones mind at the mere suggestion of such an intervention. This is particularly true given multiple articles in recent years describing many types of these surgeries being less than successful, not to mention personal stories imparted by loved ones and acquaintances of less than ideal outcomes .
How does one navigate this highly stressful decision process? I will try and impart some basic understanding about the way one should approach spine care interventions from A to Z, with Z being surgery.
First, do you and your physician truly know where your pain is coming from? If not how has the your specialist evaluated and determined in both a diagnostic and therapeutic manner this information. If so has he/she been able to clearly describe the structures and how your presentation of pain is linked to those structures. This is to say that someone telling you that you have a bulging disk or bone spurs is not being clear and is just giving you a diagnosis which is vague and therefore does not usually empower you the patient to understand or participate in the non surgical treatment of the aforementioned condition.
Without the understanding of good vs. bad pain (and yes one does stretch in the face of charley horse cramping) and concise descriptions of the natural history (meaning what happens if you do nothing) of a particular presentation, you the patient will always be making a decision with only half the information needed.
In my mind, unless the specific conversation about this information is had one should not have confidence in the decision or the professional as communication is the key to a good result with or without surgery. How did this happen, what can I do to avoid this from reoccurring and what are my responsibilities as a patient to obtain the best outcome is an important part of the interaction. The statement from a surgeon, that if it gets bad enough come back and we will do surgery, means to me that the MD doesn’t understand modern and up-to-date conservative care techniques. Nor is he truly invested in getting you better over the long run. Sending you to a physical therapist should include a specific structural diagnosis and specific information for the therapist concerning appropriate care and not just checking a box for low back pain and then for the PT to “evaluate and treat.”
So when is surgery the best course of action for you?
With that said, when is surgery the best move and when should you consider it?
Spine surgery is clearly necessary when you have emergency symptoms like loss of control of bowel and bladder function, weakness and numbness in an arm or leg. If you don’t address these symptoms quickly and with surgery, the symptoms can become permanent.
But other times, with other symptoms, non-surgical options — like anti-inflammatory medication, customized stretches and spinal injections — can be very effective. The use of pain medication and nerve stabilizing drugs may also enhance recovery. The use of appropriate stretching techniques need to be used in concert with medication if severe enough pain continues to significantly impact the patient’s quality of life.
Failing these medications by mouth, an MRI or CAT scan may be indicated based on the clinical presentation of pain distribution. From these radiographic images we may further correlate structural findings with the presentation of pain and suffering.
Many times the findings aren’t specific enough to absolutely know the source of the symptoms. A presentation of neck or low back pain as an example is often blended with different proportions of nerve symptoms. When this is the case it is important to try and modify these symptoms as diagnostic and/or therapeutic interventions help the prediction as to whether a particular surgical procedure will fully or partially resolve the symptoms.
The communication of the complexity of any part of decision making on the part of the specialist helps the patient better understand the indications and potential of any discussed intervention. The potential upside and downside of any intervention will bring out patient risk factors, hopefully helping the patient to get a head start in addressing some of these factors including poorly controlled diabetes and smoking. Failing to improve clinically in the context of the natural history and aggressive conservative care including pain management specialist interventions often pushes the conversation toward a more aggressive tact.
Selective steroid injections and sensory nerve ablation (a procedure that uses heat to desensitize a nerve which in turn lessens pain symptoms) are just two of the techniques in the toolbox of a fellowship trained pain management specialist. When these non-surgical treatment options fail to provide relief of symptoms, surgery may then become the appropriate next step. The key is to exhaust non-surgical treatment options.
It is important that all patients have a sense that they tried everything reasonable prior to deciding on surgery — unless there are emergency symptoms. Good results are expected if the source of the pain is mapped out with a good surgical plan. A great result only occurs when both the surgeon and the patient understand each of their roles around the surgical procedure as well as into the future, especially why the patient suffered the injury so they may reduce the likelihood of recurrence. Otherwise, if the patient continues with self destructive behavior (abusive contact sports, risky behavior, lifting heavy objects) more problems will happen in the future.
Your choice of physician dictates the quality of healthcare
So if surgery is necessary, what’s the difference in surgical technique?
The decision for surgical intervention can sometimes be relatively straightforward as in the previously mentioned loss of bowel and/or bladder function, a true surgical emergency. Agreeing to a surgery should include a full understanding of the potential risks and complications in that specific procedure.
It should also include an awareness of the surgeons’ expertise in such a procedure including their personal and institutional infection rate. Does the surgeon have a high volume caseload in spine surgery? Because practice makes perfect.
Also the patient should be aware that too many times spine surgeons may be biased toward using implants, screws, cages and plates that are provided by medical technology companies. More hardware is not better when it comes to spine surgery.
In conclusion, a well informed patient is crucial for a good outcome from spine surgery.
If you don’t understand what is about to happen to you — including the expectations for a recovery timeline — you should press your physician for more information.
And if your physician has a problem with you asking questions, get a second opinion from a doctor who will take the time to explain your care to you.
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