Who am I to
Who is my best
Function, or a bit
about how your
A Few Words
in Spinal Surgery
SPINAL STENOSIS SURGERY
A Few Common
things to all Operations
What Began as And Grew to Become An Education Website for The Spine Care Patient, Spine Care Learners and Those Considering Lumbar Spine Surgery.
© 2018 Drew A. Bednar MD; not for reproduction in whole nor part.
So you need a back operation, eh? Oh, my God! Just think of the pain. Massive surgical incisions on your back, being bedridden for weeks, wearing body casts or braces, taking morphine…and what if something goes wrong? Paralysis. Wheelchairs, diapers, the greater pain of torn nerves that medicines can’t control, drug addiction. Pity the spine surgical patient!
If you’ve been told you need a back operation, you know what agony awaits you. We’ve all read stories on the Internet, in newspapers and in magazines about how terrible spine surgery is, right? Every friend, neighbor and relative you never knew you had will bring you sympathy and the story of so-and-so who had it done and is in a wheelchair now. Heck, your Doctor may give you those same warnings, I hear that from my patients quite often.
Whoa, hold on here. Roughly a million spine operations are done every year in the United States alone. Then there’s the rest of the world. Where are all those crippled people? Can it really be all that bad?
It shouldn’t be, and it generally isn’t. In fact, spine surgery in expert hands can be just about as predictable and routine as zipping out your gallbladder or your appendix. There’s no beauty like the smile of somebody whose life had been falling apart because of crippling back pain or neurological symptoms when they get the full relief that can come with this wonderful pain-relieving surgery.
Okay. Having said that, gallbladders and appendixes and whatnot can be tricky and go bad too. Go into the Intensive Care Unit (ICU) of just about any major hospital right now and you’ll probably find at least one patient who has had some rare complication of otherwise routine surgery and been very ill for weeks. Things happen. Biology doesn’t come with any guarantees – and even Speedy Muffler has to make good on its warranty once in a while!
I’m an orthopedic spinal surgeon. I earn my living doing this stuff, and teaching others both about it and how to do it safely and well. But, like many of my dedicated spine care colleagues, I actually spend more time talking to my patients and their families than operating on them. People are too often terrified of having back surgery.
There is very little quality information about the experience of having spine surgery out there for our patients to look up, so responsible surgeons have to do a lot of teaching and educating. Very little has actually been written for the spine surgical patient. Check out your local library or bookstore and you’ll find material promoting drugs, therapies, surgical technology and all sorts of other “treatments” for your back pain. There is usually some elementary information about the anatomy (how the spine is built) and pathology (what can go wrong) of the spine out there, but very little about the nuts-and-bolts patient experience of having an operation and recovering from it. Most of what you’ll find on the Net is similarly commercial, and most of it is aimed at we health-care practitioners. Even the “surgical” stuff out there is usually a thinly-disguised sales pitch.
Patients often come back to my office several times to discuss things as they work on their decision to have or not have elective (“not an emergency”) surgery. Many of my office days are spent more in review and discussion than in diagnosis or proposing surgery to people. It is not an easy thing to explain the workings of the spine and what can be involved in the spinal surgical experience. It is even harder to do it in such a way that the patient will remember the discussion.
Research in patient education tells us that, confronted with the possibility of surgery, the patient listens intently to what the surgeon tells them and right away remembers 95% of it. A week later half is forgotten, and by a month the average surgical patient on a waiting list has not only bitten his or her fingernails away to nothing but remembers only 5% of what the surgeon told them about the operation.
You’d think that something so important would be keenly retained by our patients but obviously it isn’t. It can’t be because there’s a basic panic-stricken inability to think clearly and remember details that comes on when we confront a great stress - a surgeon saying he wants to slice me up would stress the heck out of me and I might know what he’s talking about better than he does!!! We should all be able to understand this challenge in processing and absorbing important information under stress because we are all familiar with it. Think about what happens when your spouse or a loved one gets really really mad at some stupid thing you’ve done and you’re getting thoroughly chewed out for it. You likely want to explain and apologize and promise “never again” but sometimes your heart’s just ‘way up in your throat and you can’t think straight at all. You freeze up, don’t know what to say or do! Ditto when confronted with surgery, no matter how calm and well informed my patient may be it’s very often “in one ear and out the other” because that stress and fear won’t let things sink in.
As a dedicated spine care surgeon and academic I frequently see “second opinion” cases. These are patients who have already met a surgeon, had all their tests and perhaps been offered surgery. They’re all warmed up! One would expect these to be easy and quick office visits for me. Nope. Guess what? Usually even more explaining goes into these visits than those of my own patients.
As an expert, I’ll sometimes see medico-legal cases where surgery didn’t go well or patients weren’t happy with the results of their care. All too often in these cases it becomes apparent that neither the patient nor the surgeon really understood either what was going on or what could be expected in the case. Nobody talked clearly, nobody was able to listen well, and nobody was happy but the lawyers. That shouldn’t happen either.
I’m often tempted to make up surgical information handouts to give out in the office. That’s a common practice but historically I’ve resisted it because I think that human contact between doctor and patient is enormously important. We have to talk. If I don’t understand you and you don’t understand me, we have no business together.
There’s a concept in business networking called “contiguous communication”, simply put that refers to actually talking in real time as opposed to texting or shooting emails around, or even reading a note or handout. There are nuances in verbal communication that are part of being human that we can’t reproduce with the written word. I can write “I love you” to anybody but when I breath it to my wife she knows I mean it (I hope…..!).
I think a similar thing happens when we sit down and take to time to be engrossed in a good book (or an educational Spine website….), there’s a deep pleasurable learning experience there that you can’t get from a handout or some quick Googling.This is also why I haven’t illustrated this website other than for two freebie Google Images on pages 79 and 80 that I use to illustrate a point tht challenges many readers. I very much want to invite you the reader to think about all this and work to concentrate enough to understand your spine condition and the careplan decisions you may be making. Glancing at some images that might be out of date by the time we publish won’t cut it. Certainly Google Images or many other sites can bring you pictures of everything I’ll present here quite straightforwardly, if you want them.
These lectures were written not just because I like to write but because my patients asked me to write them. Just about every day in the office I’ll hear “I didn’t know that…and I wish I had!” often from patients who have seen a half dozen or more professionals before coming to me. Much as I like to teach and to talk, I can’t possibly explain it all to as many people as I’d like to. Hence this website.
Most surgical back pain and neurological conditions are caused by wear-and-tear degenerative disc disease and arthritis of the spine. It’s usually in the low (doctors call it the “lumbar spine”) back. People suffering from these conditions are whom I’m writing this for. Low back pain can (rarely, thank goodness!) be caused by things like cancers, fractures and occasionally deformities like scoliosis too – but these complex conditions get a different talk and if your problem is one of those you probably shouldn’t be reading just this, you need more.
This work has four major sections. One of course (Part Four, “The Operations”) deals with the common basic surgeries. But before we get there, we have to discuss at least a bit about how your spine works, how it can be damaged and how it wears out. Your mechanic can’t fix your car without knowing how it works. We (the team of surgeon and patient) can’t go about deciding how to fix your back without knowing how it works, either.
That’s a tough assignment, because organized Western medicine (or anyone else, for that matter!) doesn’t straightforwardly “know” much of that yet. Our understanding is still very much evolving through ongoing research and experience, and what we do know from the researchers often never becomes common knowledge on the front lines of care. We know a lot about many small aspects of spine function, from biomechanics to anatomy to biochemistry to kinetics and dynamics to whatever, but we are just beginning to evolve a good comprehensive understanding or “model” of how the whole spine as a comprehensive unit works. Effectively we’ve known a lot about the trees for some time but are just starting to understand the forest. I’ve had to read and study very widely to flesh out a conceptual model in trying to understand spine function well enough to explain the problems to my patients over the years and that comes first in Part One, “Function”.
Trying to improve on that subtle craft of making people better, I read all kinds of spine-related publications and associated literature and go to several major spine care meetings annually. Over many years I’ve taken science and knowledge from many different fields and blended them together into what I think is a fairly comprehensive concept of how the spine works. It’s 99% based on science, with a taste of experience and some holistic approach blended in, tempered by an increasing understanding of behavior that comes through sharing the experiences of my patients, the teachings of my wife (she’s a registered psychologist and accredited Marital and Family Therapist) and the mellowing and wisdom of creeping middle age. As I present it, I may take the occasional liberty with proven fact – and when I do, I’ll admit it. I test a lot of it out on my own backaches (yeah I’ve got it too) and so far the package all fits.
Part Two, “Pain”, has to be here too. A common goal in low back surgery is to relieve pain, with or without associated neurological symptoms. Incidentally a great challenge tin care comes from the underappreciated fact that many spine neurological syndromes are painless – more later! So we all need to understand pain. When backache is coming from a miserable low-paid heavy physical job and the patient who just happens to have a worn-out disc in the X-rays is fine on weekends and holidays he or she likely doesn’t need an operation, they need a different and lighter job! We (surgeons and patients alike) tend to forget that as we look at X-rays and scans and book the OR (operating room). Let’s not. Remember, we all want to be happy when this surgery thing is over and done with.
Part Three, “Surgery – Common Threads” deals with issues that are common to all spinal operations. Questions like when you should have it, what medical issues lead we surgeons to consider it, how quick you might generally expect to get better, and some of those risks common to most procedures. I put this section in to minimize repeating myself later when we get into discussing the specific operations.
I am not trying to explain all the details of spinal diagnosis or exactly how we surgeons actually do the operation, that’s not the point. What I hope to do is explain the circumstances and experience of your proposed spinal operation to you in a straightforward way.
I can’t make a diagnosis for you nor claim any responsibility for the results (or not!) of your operations. Spinal diagnosis is a complex issue where the details of your symptom history and your physical exam are probably more important than any imaging test or scan, and only the surgeon you’ve consulted has that very hands-on information. We must hope that your surgeon has the comprehensive knowledge of neurology, anatomy and biomechanics required to arrive at your accurate spinal diagnosis. What I can do is help you understand something of how your back works and the issues we surgeons must consider around deciding whether surgery is right for you.
I won’t propose to be able or inclined to debate the merits of your individual case. That has to be between you and your surgeon. What I hope to accomplish is to improve your understanding of what’s involved in spine surgery so that you can have a good understanding of what to expect before and after the operation, and a correspondingly happy and straightforward experience.
I want to invite you and others suffering from spine pain with you into my consulting room at the office. A little “plain speak” goes a long way. Don’t take offense or think less of the information I’m presenting for it. What I’m presenting is very important for you, the spine surgical patient, how is just details. I will go out of my way to present it in very straightforward terms. I hope my reader will really learn something of the issues around the surgical experience, and that will mean concentrating on the reading here just as much as you might concentrate on a conversation with me.
This work is fairly comprehensive, but I won’t suggest for a second that I’ll answer all of everybody’s questions nor describe every potential outcome. You the patient may not even want to read all this stuff. That’s okay. The surgical sections are largely “stand alone” and should make sense even if you want to cut corners and go straight to them. Go ahead.
Enough said. I hope I’ve made myself clear. Now, let’s get to the point….