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Function, or a bit about how your back works
A Few Words About Pain
Common Threads in Spinal Surgery
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WHAT, AGAIN? THE PATIENT WHO NEEDS ANOTHER OPERATION, AND IS THE CHRONIC PAIN PATIENT A SURGICAL CANDIDATE?

 

Yes, some patients can need more than one procedure. Ouch!

Sometimes this happens “all at once”, such as when a surgeon advises posterior instrumentation after an anterior fusion. This is routinely done under one anesthetic, you wake up and it’s all over.

Sometimes this can be required in major reconstructions for deformity or instability, often in very old people, where the surgery we’d need to do can take ten or twelve hours or more. This just more than one should expect a patient to tolerate or a surgeon to perform safely. We will sometimes book cases like this is two or even three OR sessions, each generally a few days or a week apart to ease the strain on the patient’s metabolism. This might sound crazy but research consistently shows that (in adults, at least; kids with scoliosis may be different) that patients do better and suffer fewer complications with broken-up or “staged” surgery like this.

A problem comes up when surgery doesn’t go right, or when the problem pain is not relieved by the procedure. Face it, spine surgery is a big risky thing and you the patient will have serious anxiety around it, no matter how well informed you are. Every spine patient, somewhere deep in your heart and soul way beyond intellectual understanding of what’s going on, expects to wake up dead, paralyzed or in terrible pain.

The decision to go ahead to surgery is always a difficult one, and as soon as it’s made there seems to spring to life a great hope in the patient that surgery will work out well and they’ll be “perfect” after it.

The vast majority of the time you will wake up in good comfort and well relieved of your pain, and then recovery and the rest of your life are just peachey!

BUT if you wake up from any spine procedure and your pain has not been relieved, or maybe if your operative pain is not well controlled, it seems the anxiety around surgery can combine with those pain messages bombarding your brain cells to “break your spirit” and spin you off into chronic pain.

The same thing seems to happen to many, but not all, people who suffer very severe pain for long periods of time before considering or being offered surgery.

Medicine does not have a consistent definition of what “chronic” means. We have no diagnostic tests for it either. Basically it’s a label, a term we doctors apply to the patient. We make it simple for ourselves when we define it as a function of time, many would say you’re “chronic” if you’ve been in pain for three to six months. More importantly the really “chronic” pain patient seems to be the one who has lost hope, where depression about their unfortunate lot in life has set in and where those brain cells I labeled “XYZ” in the Chapter 2 section on Pain start to reverberate uncontrollably. The standard teaching in medicine is that there is no hope for these people, that the best we can do for them is to try to control their pain and help them deal with it through the support of a Pain Clinic.

All too often that may be true, but I’d also say that all too often these people get labeled and shipped off to the pain clinic without being offered surgical diagnosis and care that might benefit them. Certainly I encounter a lot of that in my Canadian referral practice.

Now, the chronic pain world shouldn’t get too excited here just yet. There’s no doubt that patients who suffer severe pain for years and are dependent on high doses of narcotic pain medicines will rarely do as well as more “primary” cases, and that managing them through a surgical experience is very difficult, but if a surgical diagnosis that corresponds well with the patient’s pain complaint can be arrived at, surgical care can help a great deal no matter how “chronic” you are.

Many will scoff at my saying that, and there’s a lot of “surgical outcomes research” that says I’m wrong, but consider this...in the compromised circumstances of health care in Canada where patients and surgeons have very little access to hospital beds and OR time, most of the patients a spine surgeon treats qualify (in time, at least) as chronic just because of our waiting lists. It routinely takes me between twelve and eighteen months to bring an elective (that’s “non-emergency”) patient to surgery even once all the diagnostic testing is done and the decision is finalized. Most have been in pain for a year or two before getting to me. Colleagues from across the country tell me they’re practices are generally not much better off, some worse. If the “six months makes it chronic” thing were true and there was no hope for patients who had suffered so long, I would never have a patient who did well after surgery...and most (but not all, nobody’s perfect) of mine and those of my dedicated spine surgeon colleagues do.

Remember that little issue of a 3% per year from surgery chance that something else might wear out in your spine, that you might need another procedure?

Surgeons typically teach that “your first shot is your best shot”, that only a patient’s first operation carries a high probability of success. I don’t think that’s true. If you’ve had some work done and after several pain-free years develop a new problem, you’re not “chronic” at all and you can do just as well as a “primary” or first-time procedure. I have many happy people like this in my practice.

 

 

 
         
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