When Is Surgery Justifiable?The author is observing that they only see patients who have had unsuccessful back surgeries, and believes that many of them had the surgery too soon. Reviewing their medical records, the author discovered that these patients had received inappropriate treatment and were not given exercises that matched their specific pain causes. As a result, they experienced more pain and were unable to prevent it. Some surgeons may consider patients to have "failed conservative care" simply because a certain amount of time has passed.
Surgery approaches have their own advantages and disadvantages. Fusion surgery has been found to increase arthritis in adjacent segments, while disc replacement surgery has been found to spare them. However, disc replacement surgery can lead to increased degeneration at the level of the replacement due to stress concentrations on the facet. Fusion aims to stop motion and pain, while replacement aims to restore motion and stop pain. There is no clear guidance on selecting the appropriate approach for patients. It is important to note that both approaches can still result in failures.
- Vertebroplasty is a procedure where cement is injected into a fractured vertebra to relieve pain and restore load-bearing ability
- Questioned the effectiveness of vertebroplasty in a study on over 70 patients
- Microdiscectomy techniques aim to reduce tissue disruption for disc herniation and nerve root decompression
- A trial comparing tubular discectomy with conventional discectomy and found small changes favoring conventional techniques for pain reduction
- The choice between the two techniques would depend on surgeon familiarity, skill, and patient selection
- Study pain from spondylolisthesis using three different hardware-based fusion methods and found no difference in outcomes among the approaches
A study followed up with back-injured workers who had surgery compared to those who did not have surgery. After 2 years, more nonsurgical people had returned to work compared to those who had surgery. Reoperations were conducted on a significant number of surgical cases and complications and long-term opioid use were reported. Permanent disability occurred in a higher percentage of postsurgical patients compared to nonsurgical patients. The study suggests that surgery does not guarantee the elimination of back pain and both surgical and nonsurgical patients need to manage their backs.
The effectiveness of surgical techniques can vary greatly from patient to patient. It is important to consider individual responses and not just the average results when interpreting studies. Patient selection is crucial and understanding the factors that contribute to different outcomes will lead to improved results in the future.
Following is a set of rules that I compiled that I give to patients considering surgery:
- The recommendation is to try a virtual surgery game before considering actual surgery for back pain. Many patients mistakenly believe that daily workouts will help their pain, but in reality, it is the exercises that are aggravating their condition. Instead, patients should focus on resting and avoiding activities that irritate their pain. The virtual surgery game simulates the recovery process after surgery, starting with gentle movements and gradually increasing activity levels. This approach has shown positive results in relieving symptoms.
- Surgery is recommended for neurological issues that significantly affect bodily functions like bowel and bladder control, but not for radiating symptoms such as sciatica. Radiating pain, numbness, and muscle atrophy are signs of nerve root compression. Nerve mobilization techniques have been successful in treating these conditions and should be tried first, but they require expertise and must be performed correctly to avoid worsening symptoms. In stubborn cases, approaches to reduce nerve compression or irritation may also be necessary.
- Consider surgery in cases of trauma. In such cases, the structure is unstable and needs stabilizing.
- Advice is to only consider surgery for severe and persistent pain. Patients who have surgery after only three weeks of severe pain tend to have worse post-surgical outcomes.
- Advice is against blindly accepting a surgeon's claim of being the best. The author has personally witnessed poor work from surgeons who continue to practice. Instead, asking nurses and physical therapists at the hospital for their opinion on which surgeon produces the best results. The head of a department or a speaker at a medical conference is necessarily skilled.
- Discuss the pain with a surgeon to determine the source of the pain. If multiple tissues are affected or if there is damage at multiple spine levels, the success rate of surgery decreases.
- Suggests that the term "success" can have different interpretations in medical reports. It could either mean the absence of patient death or a short-term positive outcome after a procedure. However, the focus should be on the long-term success rate in comparison to other options, along with weighing the associated risks and benefits.
- Warns against new treatments for medical conditions, specifically focusing on various methods used for stiffening discs in the spine. Claims that these treatments have not produced the promised long-term results.
- Is skeptical of disc replacement as a treatment for spine joint pain. They argue that artificial discs do not mimic the natural movement of the spine, leading to stress on other joints and potentially causing arthritic changes over time.
- The passage is that before considering surgery as the only option, one should make sure to try all conservative options first. Just because one approach like physical therapy may not have worked, it doesn't mean that it was the best option or that there aren't other conservative options to explore.
- There is a warning about institutes that claim to provide advice on surgery based solely on viewing medical images. The article emphasizes that pictures alone cannot determine the existence or severity of pain and that a comprehensive clinical assessment is crucial for accurate diagnosis and treatment.
Patient must participate in a preoperative program, if surgery takes place, the patients must engage in a postsurgical rehabilitation program to improve spine-sparing biomechanics and pain-free function.
The author against the notion that back pain is solely a social problem and instead believes that the problem lies within the healthcare system and practitioners. They believe that medical practitioners lack motivation to understand the mechanical causes, appropriate diagnoses, and treatments for back pain due to the financial incentives associated with surgery. The author also criticizes the limited time patients are given for consultations and the reliance on medical images rather than thorough examinations. They assert that a comprehensive understanding of biomechanical function and patient presentation is necessary for effective treatment.