By David Hanscom, MD.
Dr. David Hanscom is a leading orthopedic spine surgeon at the Swedish Neuroscience Institute in Seattle, WA. Though he believes that surgery and medication have a role, he knows that these standard courses of treatment aren’t what’s needed to treat chronic pain. Instead he provides the framework so the patient can find his or her solution allowing them to live free of pain, forever. His method, which transforms all kinds of pain, including back, neck, arthritis, fibromyalgia, and migraines, is explained in BACK IN CONTROL A Surgeon’s Roadmap Out of Chronic Pain.
I have been performing complex spine surgery for over 30 years. For the first 8 years I felt obligated to offer a patient an operation because “everything else had been tried” and he or she was desperate. I was also under the impression that the success rate for a fusion performed for low back pain (LBP) had a success rate in the range of 90%. In 1993 a paper was published showing that the success rate of a spine fusion for an injured worker in the State of Washington was only 15% and I had not seen any papers showing that it worked. (1) I simply stopped performing fusions for low back pain.
I currently feel that that the majority of spine surgeries performed in the US are unnecessary, especially for LBP. I don’t think that a fusion for solving low back pain should ever be done. Another study in 2006 showed a similar success rate of 24% (2) and several other papers demonstrated that there is a 40% chance of making you worse than before surgery. (3) I frequently hear, “If I just knew how much worse I would be after surgery, I never would have gone through it.” Don’t be that person.
Here are some questions to consider with regards to low back surgery:
You are the only one who is experiencing the pain. Is your pain severe to warrant the risk of surgery? No one feels that they will be the one to have complication. They do and will occur. I have seen them all.
Is your intention to rid yourself of back pain or is your leg pain the main focus? I am clear with all of my preoperative patients that surgery will not solve your back pain. Many patients will cancel surgery after that is made clear.
You should feel free to challenge your surgeon or seek another opinion.
A decision to undergo elective spine surgery should rarely be made on the first visit. Spine surgery is serious business and you need to know your surgeon and he or she needs to understand you. Imaging studies may be required before you are allowed to see the surgeon. That process implies that the surgeon is trying to be “efficient.” This scenario is not in your best interest.
Surgery should only be performed to solve an anatomic finding that can clearly be seen on a test and the symptoms match the pathway of the pinched nerve. There are many other causes of leg pain. Some examples include:
- Hip arthritis that can cause pain down the front of your thigh.
- Pain in the front of your knee may be caused be softening of the cartilage behind the kneecap called chondromalacia patella.
- Tendinitis of your band of tissue down the side of your thigh can cause pain similar to a pinched 5th root in your back.
- I have seen tumors located in the pelvis cause leg pain.
- One patient woke up paralyzed after a lumbar fusion. Her spine pathology was not that severe and the real problem was a tumor in her thoracic spinal cord.
These diagnoses are partly made by a careful physical examination. Be careful if your surgeon has not performed an exam. I have seen a back fusion performed for what turned out to be hip arthritis. Another patient had his appendix removed for turned out to be a high disc rupture in his spine.
Well before I knew much about chronic pain I would not recommend surgery in the face of a severe stress. What I now know is that stress changes the body’s chemistry and you will feel pain that you would not ordinarily feel. Stress hormones alter the body’s pain threshold. Once you can get past a severe loss or difficult situation, the pain may disappear without any surgery. Make sure your surgeon is aware of your current personal circumstances. A 2014 study showed that surgeons are assessing patient’s stress levels less than 10% of the time and hundreds of papers have demonstrated that it is the biggest factor in predicting a poor outcome. (4) Be a savvy consumer. I have been impressed that people will put more effort into researching out a new car than they do understanding the implications of spine surgery. It is not as hard to figure out as you might think. The downside of a failed spine surgery is often devastating.
Spine surgery, especially fusions is still viewed as a growth industry from the perspective of spinal device manufacturers. I recently heard a projection at a spine business meeting that there are projected to be over one million spine fusions per year by 2020. How can this be when I have not seen one research paper in my 30-year career that documents that a fusion consistently resolves back pain? There are a lot of spine surgeons and they are being encouraged by many parties, including patients, to perform procedures. You are the fuel that keeps all of this going. Be careful.
- Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903.
- Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diagnosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
- Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
- Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.