When a spine surgeon tells you not to have back surgery, you should probably listen.
I never thought I would be a neurosurgeon who does mostly spine surgery, but that’s what I do. My PhD was in cerebral blood flow and most of my residency and early career was doing a lot of brain tumors and such. Spine was a black box. When I trained a lot of cases didn’t go well, we didn’t have all the tools and our techniques were not as polished.
I have a reputation for being conservative (but I actually think it’s because I follow the national society guidelines) but do about 350 surgeries a year. I think the national average is about 220 for a neurosurgeon so for a “conservative surgeon” I do a lot. I know my trade pretty well. When I was in medical school and training in neurosurgery, back pain was something we didn’t really talk about.
It was in the “too hard” basket along with chronic headaches, dizziness, irritable bowels and fatigue.
I was taught there was no surgery done for it and surgery generally did not do well for back pain. In my residency we were just starting to put in plates and screws. I went on and did some advanced training in spine surgery at Mayo Clinic and in Toronto and learned more about fixing spine problems. I started out in academic neurosurgery. I was salaried and we basically did things because they needed to be done, not because we got paid more for them. When I started out we fixed broken necks with pieces of wire that you could buy at Home Depot for 2 bucks. At one time I was a pioneer on artificial disc surgery and published a lot. I sat (and still sit) on a lot of editorial boards and see a lot of what has come and gone. Most is fluff. Most you would not read a year later. I rode the wave of spine care.
In 20-30 years the explosion of back surgeries and spine care has been meteoric for a number of reasons. Ditto cortisone shots.
Ditto narcotic usage. Ditto expensive nonsurgical interventions. We got better at fixing xrays and MRI scans. We got better tests. We got better widgets and we had safer ways to put the widgets in. We got better at operating on sicker people. Americans got fatter. 60 was the new 40 and people stayed more active. People wanted ‘the fix’. People wanted perfection- back the way they were. We got paid well for putting those widgets in. Putting all that together, the number of surgeries, injections, pills, interventions for back conditions skyrocketed.
A Few Points To Get Out of The Way
- Back pain is common. We are all gonna get it at some stage. Sometimes severe. Sometimes debilitating but usually self limiting. 80% will get back pain at some stage of our lives and it usually settles
- We all die. We don’t want to think about it but we all die. We talked about this earlier.
- We don’t have all the answers as to why you hurt
- Our spines are falling apart, like everything else. We have amazing bodies. Miracles of biological evolution but we are not made to last. We peak round age 20 biologically and then things start to wear out. Don’t think your 40s will be like your 20s or your 60s will be like your 40s. Even hip and knee replacements, simple hinge and ball and socket joints last 30 years. The low back is 15 plus joints all working together so a little more complex
- I/we cannot give you a new back
- Most of our spine is muscle- surgery won’t fix that. There are discs, joints, nerves. Generally we can’t give you new discs or joints (see below) but we try and protect the nerves.
- Nothing stays the same. Change is inevitable.
Surgeries to Avoid
Google it. I will do it for you. You will see spine surgery right there in the mix. Top 10 surgeries not to have and right on that list is back surgery. Let’s explore why. See the link below. Old article but still good.
Fixing Old Cars
Imagine that there is a mechanic in town. Let’s call him “Bob’s Auto Repairs”. Bob has a go at fixing anything. Most of the cars he works on are older. Lots of mileage. He has no spare parts that match those vehicles. He may not have the OEM tools for that make and model of car. He cannot make any or the cars showroom quality. He just tries to keep them on the road. Typically, he rips things out. Sometimes he welds things together. Got a spring that sticks out in passenger seat? He rips the seat out. The door rattles? He welds it shut.
A spine surgeon in essence is the car mechanic fixing old cars with no spare parts.
Usually he will get the car on the road. Sometimes the car gets on the road and goes around the block and comes back in because a wheel fell off or some other unrelated problem. If you can grasp this analogy, you will grasp the essence of spine surgery. Even artificial discs are not 100% like our real discs. Most are metal and plastic. Most don’t squish. They are cartoon character versions of the real thing. This may shock you but you have to remember one thing. The main reason you have a car is to get from A to B. Birth to death. That’s it. Drive it carefully and it will get you there. Bits will fall off. Bits won’t work but it will get you there.
Sand Castles Always Fall Over
Ever made a sandcastle at the beach? For about 5 minutes it looked great! Then it fell over:
That’s our spine. The mechanic who puts the thing together says, hey nice job and in 10-25% the sandcastle falls over and something else happens. Part of it is genetics. Part of it is how the mechanic fixes it. Part of it is lifestyle but the sand castles often fall over and sometimes need more work. It’s ok. Eventually the tide will come in and wipe it all away.
Do You Like to Play Dominos?
Every watched a video where a whole bunch of dominos fall over in a line?
Back surgery can be like that. If you have a fusion 10-25% people wear the next one out within 10 years and need another surgery. Even older folks who just get unpinched find that 10% need more surgery. Blow a disc out? 10-15% blow another. Reasons? Some are genetic but we don’t exactly understand how and why. If you are obese or smoke, part of it is lifestyle. Some is bad luck. Tall people get more back issues. Golf is a killer. Many golfers are older, not in great shape and the violent bending and twisting unmasks arthritic back problems. Look at Tiger Woods. Built like a battleship but already several back surgeries:
What Works Better than Surgery for Low Back Pain?
If you have back pain don’t have surgery! Pretty simple. Avoid it. We can get great xrays and we can make MR scans look better but our honest outcomes are variable for back pain.
- Avoid the BLT:
- Go and do physical therapy. I prefer it to chiropractic because it’s active- you do the work. Get that core strong ( the middle part of your body between your arms and your legs).
- If you’re 60 and like to chop wood and your back hurts the next day, don’t ask for a surgical fix. See #1 Surgery is not for back pain. Avoid it.
- Change Your Lifestyle. Core strengthening. Weight control. Regular exercise Don’t smoke. Avoid the BLTs. Over the counter medications.
- Injections? A few are ok. Cortisone is probably safe for a couple. As a long term solution they are not great. Softens the bones. Increases the risk of fractures. Affects the immune system. We don’t know how much is too much, and to be honest, in America we do do many cortisone shots.
- Anti-inflammatories? If your kidneys are ok they are fine but watch your blood pressure and get your kidney function checked twice a year. Try not to take them every day.
- Muscle relaxants? Probably ok. Not valium
- Medical marijuana? No idea, but it sounds good!
- Pain pills? Slippery slope to being a legal junkie. You will constipate and get tolerant. Suck it up.
- Understand and accept your mortality and why nothing stays the same. Getting aches and pains is part of the human condition as we get older. Learn to deal with it. Accept you will be in some pain.
I see patients every day, in my clinic. They look comfortable sitting there. I ask what their back pain is from 0-10. A lot answer “10”. Some say “12”. I had to put up a pain chart like the one below to get the perception of pain right:
Living with pain from 1-3 is the norm. 8,9,10s don’t sit there comfortably. It’s partially mental. If you are out of work, overweight, depressed, drinking too much alcohol, unhappy at home or work, a 4 may feel like a 10.
Think About Surgery For These Reasons
Ok. So I said I do 350 surgeries a year. Clearly people are getting spine surgery, back surgery. Why are they getting it?
- Uncontrolled leg and buttock pain that interferes with their quality of life
- Weakness, either severe or persistent in legs
- Bladder and bowel involvement that is acute
- Cancer that is eating away the bones and risking paralysis that we can’t treat otherwise because of the rapid onset of paralysis
- Spinal infection with weakness, leg pain or when it’s not being controlled by medical therapy
- Broken bones where there is actual nerve damage or risk of nerve damage
- Sometimes severely crooked spines need straightening
If you look at the list, most is about protecting the nerves to legs: leg pain, leg weakness, loss of bladder and bowel control. Not back pain. Don’t do it.
What About Lasers, Virtual Reality, Robots, Minimally-Invasive Surgery?
This is where we enter the snake oil world.
A lot of docs get paid for what we do. The more we do, the more we get paid. It’s a system that we live with and a system that is open for corruption. I am known for trying everything short of surgery. If I get your back pain better with a shot and some therapy i get a fraction of what I would get if I actually operated on you, particularly if I put widgets in you. If I put widgets in you the company that makes the widgets thinks I am a great guy, the hospital loves it because I make them more money and i get paid more. The company may offer to pay me as a consultant. I should declare that in everything I say and do, but many don’t. Get the drift? The more we do, the more we get paid. It really relies on the conscience of the doctor to do the right thing, and most do. Spine care is like a restaurant. Surgeons, PT and pain docs need to get bodies through the door. If you can show you have the latest widget you may attract more customers. We talked about this in finding your surgeon. Most are gimmicks. Lasers are gimmicks. Robots are gimmicks (they aren’t really doing the surgery, just showing the surgeon where everything is). Virtual reality is a gimmick. A lot minimally invasive surgery is a gimmick. Twenty years ago patients who had a lumbar fusion had a foot long incision, bone graft taken from the hip and a weeks hospital stay. Now you can do it through 4 inches, no hip graft and home in 2 days. It’s not what the purist would call ‘minimally-invasive’ but every surgeon can do it. That’s what we trained to do. Most is marketing and hype. I’m guilty of it. Buyer beware.
You don’t want a gimmick You want your problem fixed with the highest success rate and lowest risk.
That’s it. If you want Bob’s Auto Shop to use a laser or a VR headset to fix your leaking radiator that doesn’t work, go for it, but maybe you just want a working radiator without anything else being screwed up.
What Does Back Surgery Work For?
Mostly leg pain, leg weakness, bladder and bowel disturbance (which is usually dramatic and acute). The effect on back pain is hit and miss
Do Your Homework
I have already given you the tools. Find the right surgeon. Ask the right questions. The big thing however is avoid spine surgery if you can. My colleagues may hate me saying this, but it’s the truth. Accept that we all hurt some as we age. Moderation is key. On a personal note, my dad, a physician had 2 back surgeries, one a fusion and hurt till the day he died. He had a great surgeon. His x-rays and MRI scans after surgery looked great. He was miserable until the day he died. I could not fix his back pain. Surgery did not fix his back pain. Avoid it if you can.
[As a side note, I don’t get money from companies for putting in implants. I have had payments from mainly nonprofits for teaching. I also own a small share in surgery center. You can look me up here and compare me to the national average if you like.]
I’m sure I have stirred up a lot of colleagues with this. Questions? Comments? Feel free to comment and please share!