Hi my name is Dr. John Shim and today I'm going to talk about the situation when the surgeon recommends against spinal surgery. Some of you will come to see me after you've had that recommendation and usually you're quite distraught, but you had to think about why somebody why a surgeon would make that recommendation against surgery. Most of the time is because the studies, the x-rays, the cat scans and MRIs do not match your physical examination findings. Surgery may not and usually does not benefit you if we do operations in that scenario that's why a surgeon would recommend against surgery in that scenario. The second category why a surgeon would recommend against surgery because the risks are too high, unfortunately we have lots of people who have a lot of medical problems. You have a bad heart, you have a bad lung, you have horrible diabetes or you have some issues with obesity. The risks are very very high. Surgeons we can do the operation, we know we can finish the operation but if we're concerned that you will not do well, you'll have complications such as a heart attack or bad infections or worsening complaints after the operation. Usually a surgeon would recommend against the surgery. The third category and why a surgeon would recommend against surgery is because the expectations are just too high. As surgeons we know we can restore people back to certain levels of function. If you're 65 years old we can return you back to an average 65 year old person, we can't return you back to 21 well if you're not realistic about that you're going to have a very disappointed outcome. If you're not realistic about what the surgery can accomplish for you most of the time most surgeons would not recommend the surgery. Now understand that i'm talking about when the surgeon does not recommend surgery. There are certain instances where well trained experienced surgeons will refer you to another Center for more surgery, usually it's because the amount of surgery you need also requires a team approach to management of your care you need something like a university setting where you have other doctors other teams residents fellows who are basically taking care of you round the clock to make sure you give better. In that scenario many doctors would recommend you to go to a more academic institution, but understand your surgeon in that point still has recommended surgery. The people that I'm talking about are the ones that the doctor said you probably should not have surgery or I see no reason for surgery. If that is the discussion you must consider number one dose my studies match my physical exam findings, number two are the risks reasonable considering my condition and number three am I being realistic about the surgery? This is Dr. Shim talking about a very difficult topic, Thanks for listening.
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:
- Physical examination findings do not match the identified problem on diagnostic testing.
- Pain complaints do not seem consistent, or are out of proportion to the findings on testing.
- The identified condition is too diffuse, and successful surgical outcome is difficult to predict.
- 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. “
- 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.
- 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.
- 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