There are legitimate reasons why a Surgeon will not offer elective spine surgery on patients.
Bear in mind, we are talking ELECTIVE SPINE SURGERY, not emergency surgery. As you know, elective surgery may definitely be warranted, as the patient has debilitating pain, or loss of function that does not improve with non surgical care. The surgeon, however, must match the complaints to the findings on diagnostic testing, and also gauge the patient expectation. If there are inconsistencies among those factors, the results may be an improvement after surgery, but unrealistic expectations will deem the surgery a failure, by the patient. Unfortunately, poor outcomes do happen. A prudent surgeon will do what he or she can to minimize these poor outcomes. Sometimes, that is by refusing surgery.
As a surgeon, my goal is to help patients with their surgical needs. In emergent situations, I am called to try to resolve a potentially limb or life threatening situation. While patient expectations are also important, in emergency situations, the pressing needs to save the situation is primary. In emergency situations, while the patient expectations and outcomes are important, equally important are the community expectations on treating emergent situations. Patients who refuse emergency operations are required to sign documents indicating refusal of emergent treatments Against Medical Advice.
As far as elective spine surgery goes, surgeons have the right to refuse surgical treatment if there is no emergency situation. As many patients think their situation as emergent (although medically, it is not), they question the refusal, and demand surgery. Often times, there are specific reasons surgery why will not be offered:
1. Physical examination findings do not match the identified problem on diagnostic testing.
2. Pain complaints do not seem consistent, or are out of proportion to the findings on testing.
3. The identified condition is too diffuse, and successful surgical outcome is difficult to predict.
4. The patient, and family may be unrealistic about the effects of surgery. As I like to say, ” if you are 60 years old, the surgery will return you back to being 60 years old. The surgery will not make you 20 again. ”
5. The patient may have comorbidities such as obesity, diabetes, or respiratory problems that will make the surgery likely to cause more problems than it will fix.
6. There is a need of a much more complex surgical procedure, one that is not amenable for proper management in a private practice setting. Sometimes, the surgery is too large in scope. Certainly, the technical aspect can be performed by any competently trained surgeon. The aftercare, and monitoring necessary during and after surgery may not be available in all hospital settings. These surgeries may be better off in a Tertiary, or Teaching Hospital Environment.
7. The technique desired by the patient is still experimental, with no proven track record. In the past, I was involved in FDA trials of new technologies. The “study patients” had tremendous guidance and followup. The prime objective was always the safety of the patient. If you want experimental treatment, please get enrolled in one of the studies. Use of experimental procedures, otherwise, has a fair amount of medical and financial risks. I do not perform any experimental surgeries any more. If you want this type of surgery, please look up studies in ClinicalTrials.gov. There are over 700 trials going on that are being monitored by the FDA. In my opinion, this is the safest way to participate in experimental spine surgical procedures.
In the end, surgeons decline to offer elective spine surgery because they cannot predict a good outcome, or the procedure desired is experimental. Frankly, it is my opinion that surgeons who refuse elective surgery are probably trying to do what is best for their patient. As you all know, you can always find someone to do your surgery. There is too much incentive for many surgeons to just go ahead and operate. If a surgeon says no, there must be a very good reason. Please take that into consideration and remember, you can always get a second opinion, but research your surgeons first.
- Fry DE, Nedza SM, Pine M, Reband AM, Huang CJ, Pine G. Inpatient and 90-day post-discharge outcomes in elective Medicare spine fusion surgery. Spine J. 2017 Jun 27; PubMed PMID: 28662991