As a Spine Surgeon, I want to give my patients a chance at a successful outcome. But, I find some patients to be unrealistic about the goals. So the topic can be broached, I thought I would share my thoughts on the Goals of Spine Surgery. As we will see, there are many considerations to spinal surgery. As always, these are my opinions. If you disagree, luckily as the reader, you have the option of going to another webpage or site!
Before we go into the goals, we must briefly discuss why you even would consider spine surgery. In the emergent situation, you should not be reading this Blog. You should be getting to an evaluation ASAP. Fortunately, the emergent situation is rare. It usually involves a significant injury from a fall, or accident. In other instances, it is an impending paralysis event caused by infection or a tumor. If you are experiencing severe pain, with developing loss of muscle control, see a physician right away. This dicussion is not for the emergent situation.
The vast majority of patients who decide on Spine Surgery are people who no longer can tolerate the pain associated with their neck, back, arms and legs. There are also some who have severe associated headaches. After exhausting non surgical treatments such as time, medications, activities modifications, therapies and injection, these people often seek a surgical solution. Please note that I am limiting this discussion on patients that have pain, but not functional impairment. This discussion is about Elective Spine Surgery. And, often times, they will get conflicting opinions on the chance for success. That is because each participant in the surgery may have a different goal.
For the patient, please have a thoughtful discussion on the definition of success. This becomes a re occuring theme in relationships between surgeons and their patients. The Surgeon may be correct in that the reason for surgery has been successfully managed. But, for the patient, the goal, and the definition of success may be different. Please discuss the expected outcome of the successful surgery from your perspective as the patient, as well as the perspective of the surgeon. The surgical goals of the surgeon may have been accomplished, but the patient may still be disappointed.
To give an example, I often see patients who are developing cervical myelopathy. That is a progressive process by which the spinal cord is being compressed in the neck. It starts as a neck pain, then progresses to weakness of the legs and arms. From the perspective of the surgeon, the goal of the surgery is to stop progression of the process by making more room for the spinal cord. Making room for the spinal cord is often achieved and confirmed when additional studies are performed. The patient is aware the surgery was designed to make more room for the spinal cord, and thus may prevent the long term progression of the myelopathy. But, also, the patients had other assumed goals, that were not fleshed out in the discussion. Often times, patients want to return back to a previous level of function, WHEN THEY WERE 20 YEARS YOUNGER. This is just not possible by surgery. AS I explain to my patients, the goal of surgery is to give you a chance to get back to age appropriate function. A 60 year old, would have a goal to being able to do what an average 60 year old would be able to do. Unfortunately, with all the marketing hype on the airwaves and the internet, the perceived promised goals are often not realistic, and mostly manufactured by the marketing arm of the various medical entities.
As far as the Goals of Spine Surgery, the surgeon should also be able to give an estimate on the chances of obtaining a realistic goal. Again, if your Goal is to be younger, it is not likely. The scenario I often see is the patient that has disk problems in multiple locations. There is significant pain, but it is difficult to isolate the pain to one area. Because multi-level surgery may be necessary, the chances of a successful outcome is not great. In addition, because of the likely added risk of prolonged surgery, there is also an increased risk of complications such as infections, anesthetic risks, and bleeding. In this scenario, the patient must understand the risk. This is the part many do not like. The patient must also understand that sometimes their situation may be such that the risk of surgery, and susequent outcome may not be worth the effort. The patient may need to accept that their current situation may be better than a bad surgical outcome.
Many do not want to accept that opinion, and it is understandable. If they can afford it, they can get multiple opinions. At academic tertiary centers, those physicians may be in a position to manage some of the risks better. But still, patients must be realistic. In very complicated situations, with a risky profile, there is still a chance that you will be much worse off after surgery. As I often say to my patients, just because it can be done, does not mean it should be done. And, surgery is not reversable. I am saddened to see patients back after I recommended against surgery. They proceded, and now want another opinion on how to reverse the surgery.
In my practice, I try to limit the Elective Spine Surgery to situations where there is a predictable outcome. For the most part, that is lumbar laminectomy/disectomies, anterior cervical discectomy and fusions, and on a very infrequent basis, single and double level lumbar fusions. There are many talented surgeons that do the much more complicated procedures, and have helped those patients. But, after more than 20 years of practice, I will say that I have limited my practice to only the most predictable procedures, as those are the patients that have the best chance to return to function, work, play and enjoyment.
- Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int. 2014;5(Suppl 7):S295-303. PubMed PMID: 25289149