Do I need surgery for back or neck pain? This is a common question that we regularly receive from patients facing a surgical consultation for back pain. Unfortunately, there is no universally applicable answer for all patients.
Statistics are grim when it comes to treating common forms of back and neck pain surgically. Virtually all quality investigational studies have proven that surgery demonstrates no benefit when compared to nonsurgical therapies. Worst still, the incidence of complications and collateral health consequences caused by surgical interventions continues to rise year over year.
The surgical consultation itself is a frightening experience and can do tremendous harm through the power of the nocebo effect. Therefore, patients are cautioned to prepare themselves for the evaluation using this easy-to-follow guide.
In this essay, we will discuss surgical consultations for neck and back pain in order to help maximize chances for effectual treatment. We will provide guidance on the types of questions to ask the surgeon, as well as shed light on some warning signs that might contraindicate surgery as the best course of treatment.
Surgical consults are usually recommended for patients who suffer from several distinct varieties of acute or chronic dorsalgia. Most surgical evaluations are indicated for patients whose pain has not resolved with time and conservative care or for patients whose pain has worsened despite receiving nonsurgical therapy. Some surgical consults are ordered in cases of acute trauma, even when the pain is the result of a fresh spinal injury or when the patient demonstrates serious neurological impairment, such as in the cases of cauda equina syndrome, paralysis or incontinence.
Surgeons are usually scheduled by referral from a primary care provider or from a nonsurgical specialist, such as an orthopedist, chiropractor or neurologist. When it comes to back pain surgery, patients must seek out a specialist who focuses on the spine and preferably, the exact diagnosis presented.
Surgical evaluations usually involve the surgeon reviewing diagnostic films and studies, then talking to the patient and possibly performing a physical exam. This last step is crucial, but is rarely actually performed. Unfortunately, so many surgeons allow the structural abnormalities on the diagnostic images to guide them exclusively towards accepting or denying a patient for surgical intervention. This is a dramatic mistake, since a physical exam is one of the most valuable tools in a doctor’s arsenal and has been objectively proven to assist in providing improved therapy results, regardless of the type of treatment to be rendered.
Sadly, a physical exam takes time, which is something that most surgeons do not allow for during a 15 to 30 minute consult. If they did, many patients would fare much better, regardless of the course of their future treatment.
Once the doctor has reviewed the patient profile and diagnostic imaging, they will determine if the patient is deemed a good or poor candidate for surgery. Then a recommendation will be made to pursue invasive care or an alternative may be suggested in lieu of undergoing an operation.
Facing a surgical evaluation can be a terrifying experience. After all, back surgery is a very serious occurrence that can leave permanent effects, both good and bad, on body and mind. We have witnessed many common problems with the surgical consultation process, which we will now detail to help patients make better informed choices when scheduling exams, seeing surgeons and making final decisions on whether or not to undergo surgery:
Surgeons are business people. Some are ethical and without reproach, while others will cut into their own mother for a dollar, even if she does not require an operation. Finding a quality surgeon, in terms of technical proficiency, might be easy. However, finding one who places the patient’s overall health and wellness above the potential to make money can be a challenge.
Remember, surgeons operate. This is the primary service they provide. This service is highly profitable and if surgery is not recommended, they do not make money. Therefore, do not be surprised if a verdict recommending surgery is pronounced, simply due to the economics of the decision. Many clinical studies cite that up to 95% of all back surgeries are unnecessary and at least half of these might have been performed for purely financial reasons.
Surgeons might not outwardly recommend or deny surgery as the best treatment. They might simply allow the patient to decide for themselves. However, may will impart a nocebo effect during the consultation, which is a common problem referred to by Dr. Andrew Weil as "medical pessimism".
This nocebo might be subtle, such as “You will probably need more invasive care in the future” or “Some patients who do not have surgery suffer worse pain”. The nocebo might also be dire, such as “You must have surgery or you will become paralyzed or incontinent”.
We have seen all manner of nocebo effects and have suffered them ourselves dealing with our own health problems in the past. Nothing surprises us at this stage and it is worth mentioning that many nocebos are bestowed purposefully in order to force a patient to acquiesce to surgical intervention or as an inherent part of the litigation process for back injury.
If surgery is not advised, many patients are sent back to square one and are not sure where to go from there. Their other doctors do not have any answers, which is why they were sent for a surgical consultation in the first place. This forces many patients to seek multiple new opinions, often landing them back in trouble with one of the scenarios presented above. Many of these patients were lucky to find an honest surgeon the first time and not be forced into unneeded butchery. However, they might not be so fortunate on subsequent tries and eventually might suffer serious consequences as a result of the frustration, pain and limited treatment options, when a less selective surgeon accepts them, makes their conditions worse and then abandons them. Sure, this sounds harsh, but we have witnessed its occurrence thousands of times over the past ten years of advocacy work.
Many patients find themselves in a “damned if they do and damned if they don’t” position when facing a surgical consult for back pain. If they receive a recommendation for surgery, they might not trust the intent of the doctor and might not be able to proceed confidently forward. If they do proceed, the procedure will likely fail to permanently resolve their pain (proven statistically and not in any way editorial opinion) and they might suffer lasting health effects leading to disability or even death.
If they do not agree to surgery, or are not indicated as ideal candidates, their options are incredibly limited and will usually involve other extreme risks, such as multiple epidural injections or long-term pharmaceutical therapy at the cost of overall wellness.
There are no easy solutions for patients facing surgical consultation.
We know that the tone of this essay paints a grim picture. However, there are already dozens of articles on this topic elsewhere on the web that do not provide any real guidance or cautions for patients facing a surgeon’s evaluation. We just needed to provide a balanced and realistic view of this highly important topic, especially since so many of our readers write to us with negative experiences arising from these vital surgical consults.
Many spinal surgeons are excellent and will never place their financial aspirations above the best path for their beloved patients. Others are average and will often perform procedures that they know have little hope of providing a cure, as long as the patient seems to desire the operation. Some surgeons are ruthless and will virtually trick, intimidate or otherwise coerce patients into completely unnecessary operations that might injure or kill. Unfortunately, it is difficult to know which type of surgeon a given provider truly is on any given day until it may be too late to do anything about it.
First and foremost, educate yourself about your diagnosis and therapy options. Some diagnoses respond better to surgery than others. Some diagnoses involve treatment that might be worse than the condition itself, especially those involving large scale spondylodesis techniques.
Understand that most back surgery is not needed, nor does it stand a very good chance of resolving pain, even if the technical objectives of the operation are flawlessly performed. In essence, many surgeries are deemed successful because the structural goal is achieved, (herniated disc reduced or removed, spine actually fused, impinged canal opened, etc), yet the patient does not enjoy any symptomatic benefit. In fact, many patients have more pain postoperatively, even when the procedure is called a complete success. Note this fact and make decisions accordingly.
Understand that spinal surgery comes in a staggering variety of procedures and levels of invasiveness. Therefore, most patients are advised to seek out the procedures that have the best chance of resolving the problematic condition, while causing the least amount of damage to the anatomy. This usually means finding a surgeon who specializes in minimally invasive operative techniques, such as laser back surgery, fiber optic-guided surgery or tool-through-catheter approaches.
It is always best to get multiple professional opinions on the quality of a surgeon, prior to seeing them for evaluation. Ask your doctor if they would send their own mother to see this surgeon and watch carefully for their reaction.
Do not see just one surgeon. Instead get multiple opinions, from a variety of different types of surgeons, including neurological and orthopedic specialists. Do not share one doctor’s findings, recommendations or prognosis to taint the next doctor’s objectivity. If you have to pay for multiple opinions, consider it a worthwhile investment in your life.
If you do decide on pursuing surgical intervention, do everything to increase your chances of a successful result. Get in the best shape possible prior to the operation. Hire the very best doctor. Discuss every aspect of the surgical process and recovery period to identify potential problems before they occur. Most of all, have a positive mindset, based solidly on work you completed to make the decision to undergo surgery. If you did everything right prior to the first surgical consultation for back pain and decide to proceed forward, then you have already accomplished much towards attaining a better-than-average result. Best of luck and please share your own surgical experiences on our interactive patient forum.