What To Ask Your Spine Surgeon

What To Ask Your Spine Surgeon

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.

David Hanscom, MD

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.


  1. Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903.
  2. Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
  3. Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
  4. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.

 Website:  www.backincontrol.com

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Authored by: David Hanscom, MD

There are 8 comments for this article
  1. Vanessa Gray at 11:43 pm

    Spine is indeed one of the most important parts of our body, as well a part of body that usually becoming in pain in old age. That can be very problematic. So in order to prevent yourself from such problems you should simply follow the instructions from the early times of your life. The instructions include spine exercises in daily routines as well chiropractic therapy once in a month. It is a technique to relax the muscles by naked hand.

  2. Michael Wagner at 4:39 pm

    Dear Doc Hanscom,

    Years ago I had a L-4,5 and S-1 with steffe plates and got a screw rapped around the L-5 nerve root and the tip of the screw well into the spinal canal, it took 6 weeks before they took it out.
    Dr,s then told me it would grow the nerve back at 1 cm a mont , well that did never , but I have to say you are right about not having surgery, I think I would have been much better off, as all it did was lead to another fusion. this should be wrote o
    And told to the patient before anyone does surgery on you.
    I have tried all there is and can be done to relieve this aa pain including trips to Asia for Chineese therapy, herbs, accupunture, 3 times a week for 6 weeks , they gave up and said modermedicine might be best for me, I stayed away from opiates for many years after, and finally gave in , strange thing I never got a high from opiates, I never asked for a increase, but now they want to change things, why change something if it works, well they did change things only to make it worse, they tried to bring it back to that working level but that didn’t work as it was lodged in the brain, it looks like it should have never been messed with.

  3. Mona Twocats-Romero at 10:05 pm

    There is something that works great out there. Opiates; but no one will prescribe them, because instead of advocating for their patients with pharmacies and the government, including the CDC, FDA, DEA, and Congress, they’d rather turn tail and run to save themselves and their income. Not that they should be forced to do anything different, but I thought my pain team would at least TRY to keep me on an effective dose. I have said here before I am on approximately one-quarter the dose of opioids I was when I joined the team ten years ago, even though I have developed much more pain due to osteoporosis crushing my spinal nerve; exacerbation and advance of my DDD causing arthralgia all up and down my spine; among other things, like my diagnosis of fibromyalgia and chronic pain syndrome; my C4-7 fusion, etc. I am shocked that none of the pain team seems to even be worried about this other than my Clinical Psychologist/Therapist. Suicide is beginning to look more and more like my end point.

  4. Angie Self at 7:05 pm

    I have been diagnosed with a compression fracture at T12. Also have been told my entire spine is bone on bone. Is there any treatment available for me?A spine surgeon has said there is nothing he can do for me. I am in chronic pain.

  5. Dorlee at 10:53 am

    Thank you for such an honest opinion. I have had upper and lower spine issues most of my life. After they figured out it wasn’t “growing pains” and I was so young, we just waited. All of the doctors I saw recommended I don’t have surgery, it doesn’t always work and can make things worse. I never thought it was worth the risk. The herniated discs in my lower back did sort of heal up on their own, took 20 years and they only bother me once in awhile, I just make sure I am careful. Have always been glad I never had surgery. My back has pretty bad degenerative disc disease now but with medication (and a host of other things) I get by. I actually had my records sent to Swedish Spine Institute for review. They said there was really nothing they could do, just continue on with pain management. Now, if only pain doctors did not feel obligated to continue to reduce medication I would be better. Still glad I did not have surgery.

  6. Mona Twocats-Romero at 10:51 am

    Dear Dr. I am afraid that your suggestion that all spinal surgery is unnecessary is not defined clearly enough. Either that or you are just flat wrong. I was suffering from intense pain from degenerated disks and spinal stenosis in my cervical C4-7 area. After surgery I am much better and have been for years after the C4-7 fusion. My spinal stenosis was so bad that my surgeon told me my spinal cord was going to “fail” if I did not have surgery. I had already lost bowel and bladder control and was in constant severe pain. I still have chronic pain from breakdowns in my thoracic and lumbar spine, but have not had surgery on them. I also have fibromyalgia, osteoporosis, and congenital deformities in my spine and feet that I don’t want to pursue surgery on, but the cervical spinal fusion was the right decision.

  7. Ibin at 8:14 am

    After 3 months of “leg” pain, I truly thought the pain was due to a hip, joint condition. I was referred to a surgeon by my general MD of some years. The surgeon upon an evaluation stated that, the pain was generated from a “disc” problem in my spine.

    An MRI, “revealed” a herniated disc. The surgeon, in fact, prescribed non opiate medications for a full year “hoping” the disc inflammation would decrease. The pain was persistent, and “seemed” to increase. The surgeon advised that after a year, surgery was necessary.

    The surgeon advised me that the procedure would reduce the persistent pain level to about 75% less. I can live with that. I’m a “blue collar” worker and used to minor pain.

    The surgery went well but, pain persisted another year. Along the way, I was prescribed a low level opiate pain reliever. Of course, the reliever “lost” its’ effectiveness as the body adjusted and became, tolerant. Upon another MRI, a year later from surgery No. 1, another disc was discovered to be herniated. Probably from the “good” disc carrying weight from the first one “repaired”, he advised. A “fusion” with plates and screws was “in order”.

    Just before the procedure, the surgeon in a preparation for procedure office visit stated and I quote, ” You are going to apply for disability”? I was very taken in. I really thought I was having a procedure so I could continue to work. Some “normalcy” in life. Some sleep. Some escape from continuous, severe pain.

    The surgeon stated that he would use “plates and screws” to bridge over the two “failing” discs. I understood the application. He also stated that IF you intended to work, this would be your best “shot” at it. It wasn’t that I wished to work, it was that I HAD to work. Two children in college, a home mortgage, a car payment, utilities to pay for, food to buy, health insurance premiums, and debt recurrence responsibilities that a young family has.. The “surgery” was deemed a “success” by the surgeon, of course. However after surgery heal time, I was in worse in more continuous pain than when I “started”.

    Opiate medication after the surgery, was prescribed for about 6 months when the surgeon stated that he could no longer prescribe to me. He stated, that I “shouldn’t” be in such severe pain. I suppose that is why he stated “You ARE going to apply for disability” before the surgery. A contradiction that now had my family, myself, in a he$$ of a “mess”.

    No “other” choice, I was refereed to a pain management specialist. I had already been through physical therapy, steroid injections, and the “normal” procedures prior to referral to a “specialist”. I had even seen a chiropractor after surgery. Maybe should have went BEFORE surgery?

    I TRULY trusted “modern medicine”. I thought that a pain management specialist did have alternate treatment methods to relieve pain or a methodology for me to “do” to reduce pain, myself. I was immediately prescribed an opiate medicine without, acetaminophen. The specialist cited 20,000 people a year die with liver, kidney problems FROM the use of acetaminophen. Including over the counter meds, as people did not medicate in accordance with advised dosage. I was prescribed an opiate based medication without, acetaminophen “for my own health good”.

    The nature of opiates, as we all know, loses effectiveness, with the SAME dosage, over an extended period of time. An increase is highly likely with life long pain.

    Long story shortened, as a patient of over 20 years, I WAS eventually prescribed 160 milligrams of medication, per day. 6 years ago. In the interest of my own health, I reduced usage to a tolerable pain level, have been stable on 100 mgs per day, with regular visits, drug “screening”, STILL working, as happy as a pain patient can be, until the “guideline” was introduced to me in June, of 2016. The 90 mme daily and subsequent reduction of medication was not “started” until January, 2017. Presently, at a lowered dosage of 80% from 100 mgs per day to, 20 milligrams, 90mme daily now, I am no longer working, I have a disabled spouse of 39 years, we are burning through life savings, with no other path to trod.

    I have tried all the herbal and “plant” properties that are legal in my state and have no recourse available to me and my spouse as she has been reduced 66% on her medication.

    I suppose in retrospect, maybe I did not ask the surgeon the “right” questions. I didn’t have much choice for procedures, as I “listened” to the surgeon. WOULD I have acted differently? Maybe, I counted on the “expertise” of the doctor. HE only acted in accordance of then, 20 years ago “procedure” to relieve back pain. Prematurely? I don’t know. PAIN was affecting my life so bad, I was worried about providing income then, as well as now at 58 years old. I can only say now, question what you are “getting into”. SEEK former patients with similar prior procedures. Ask prior patients of the same doctor. Medication as of now, maybe forever, may NOT be available. 90mme daily, in my “experienced” opinion, is a disaster for pain patients. Life wrecking, life limiting “policy” causing undue hardship because a pain patient “MAY” misuse medication. Even if “screened” heavier than an international flight baggage check. Good Luck!

  8. Maureen at 8:01 am

    Dear wonderful Dr. Hanscom,
    I give you a big hug!
    In my regard…you hit the nail on the head! I am so grateful for your post since it tells me that I’m not crazy when I say ‘I should’ve never had those fusions.’
    Or, ‘if I knew then what I know now’. I could write a book here about my experiences but I know that you already know my story, over and over!
    I truly was much better pre-surgery than I am now.
    After many years of debilitating pain since my fusions, hardware, removal of hardware etc etc, becoming disabled, having to live on meds,
    and sadly having to say goodbye to my 32 yr. nursing career/my livelihood,
    and basically my life since 2004…
    I have also greatly suffered emotionally at the hands of my surgeons etc…
    I have learned over the years (through several 2nd opinions (post op!),
    research and talking with other patients, that my spinal condition did not warrant the surgeries I endured.
    I truly believe that I would still be working and enjoying my life as it was, had I gone another route or had been recommended for myofascial release therapy etc. Structurally I was not that bad off pre-op.
    I believe a lot of my pain was tight muscle driven which effected my nerves etc.
    I have tried many modalities since and now know that had I done some of that therapy prior to surgery I’d possibly be so much better than I am today.
    I’m so broken now and always will be.
    Knowing what I know now brought me to come to my senses and cancel a ‘5th’ fusion this past Jan….
    I finally saw the light! 🙂
    Please continue to be a voice in this direction for as long as you can.
    You are the ‘awesome advocate’ for many a folk who have suffered from failed spine surgeries and the never ending lifetime painful effects from them.
    Thank YOU!
    With great Gratitude, Maureen