Function, or a bit about how your back works
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Common Threads in Spinal Surgery
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A Surgeon’s Guide to The Spine Surgery Experience for the Spine Surgery Patient
No Bull – A Surgeon’s Talk to the Surgical Back Pain Patient.


So you need a back operation, eh? Oh, my God! Just think of the pain. Massive surgical cuts on your back, stuck in bed for weeks, body casts, 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 in newspapers and 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....

Whoa, hold on here. Almost three quarters of 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 can be just about as predictable and routine as zipping out your gallbladder. There’s no beauty like the smile of somebody whose life had been falling apart because of crippling back pain 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. 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 on death’s door 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. But, like most of my colleagues, I actually spend more time talking to my patients and their families than operating on them. People are often terrified of having back surgery.

There’s very little information about spine surgery out there for our patients to look up, so we 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 a lot of material selling you drugs, therapy and all sorts of other “treatments” for your back pain. There is some information about the anatomy (how it’s built) and pathology (what can go wrong) of the spine out there, but very little about the nuts-and-bolts patient experience of surgery. Most of what you’ll find on the Net is similarly commercial, and most of it is aimed at health-care practitioners. Even the “surgical” stuff out there is usually from some company or other selling their surgical tools and devices.

Patients often come back to my office several times to discuss things as they work on their decision to have or not have 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 the next day remembers 95% of it. A week later 50% 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.

As an academic, I frequently see “second opinion” cases. These will often come from very respected colleagues. These are patients who have already met a surgeon, had all their tests and 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 those visits than those of my own patients.

As an expert, I’ll often see medicolegal cases where surgery didn’t go well or patients weren’t happy with the results of their operations. All too often in these cases, it becomes apparent that neither the patient nor the surgeon really understood what was going on in the case. Nobody talked, nobody listened, 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 and one that saves time in the office. Historically I’ve resisted that 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.

This book was written not just because I like to write but because my patients asked me to write it. Just about every day in the office I’ll hear “I didn’t know that...and I wish I had!” Much as I like to talk, I can’t possibly explain it all to as many people as I’d like to. Hence this book.

Most surgical back pain is caused by wear-and-tear degeneration of the discs and bony joints of the spine. We call it “degenerative disc disease”, also “degenerative arthritis of the spine” or “spondyloarthritis”. It’s usually in the low (doctors call it “lumbar”) back. People suffering from these conditions are whom I’m writing this for. Most backache is really muscular and if you’ve got occasional aches and pains after a busy day this book’s not for you. Low back pain can (rarely, thank goodness!) be caused by stuff like cancers, fractures and 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 this.

This book has four major sections. One of course (Part Four, “The Operations”) deals with the common surgeries. But before we get there, we have to discuss how your spine works and how it wears out, no? 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 really know that yet. We know a lot about many small aspects of spine function, from biomechanics to anatomy to biochemistry to whatever, but we don’t have a good comprehensive understanding or “model” of how the whole spine as a unit works at all yet. Effectively we know a lot about the trees but we don’t understand the forest. I’ve had to flesh out some concepts of such a model in trying to explain stuff to my patients over the years and that comes first in Part One, “Function”.

No, I didn’t just make it up. Trying to improve on that subtle craft of making people better, I read all kinds of back pain literature like a fiend and go to several more spine meetings every year than I can really afford to. 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. As I present it, I may take the occasional liberty with proven fact – and when I do, I’ll admit it.

Part Two, “Pain”, has to be here too. The whole point of these surgeries is to relieve pain. 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, OK? 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 the patient in a straightforward way.

I am intentionally keeping the tone of this book simple. I don’t want to snowjob you with tons of literature references. If you want a textbook, go read a textbook! Nor will I present an erudite polysyllabic tome commensurate with a comprehensive education and the thirty–seven different letters (no kidding!) I can legally put after my name. I want to invite you and others suffering in 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. I will not apologize for going out of my way to present it in very straightforward terms.

This book is fairly comprehensive (read, I talk too much). It’s not perfect, and I won’t suggest for a second that I’ll answer all of everybody’s questions nor describe every potential complication. You the patient may not 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....

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