When Spinal Surgery Makes Sense (And When It Doesn’t)
Pain doctor in Amarillo discusses
I am going to tell you some things that may be eye-opening and are facts based on research that you probably have never heard before.
Here at Creek Stone Integrated Care in Amarillo, TX, I see patients daily that are here to get out of pain. That’s normal. But, many of them are desperately trying to avoid surgery on top of that. Many times, they have been told that surgery is eventually going to happen whether they want to do it or not. How frustrating that must be. Not only can that be frustrating, but it can be absolutely frightening as well.
Before diving in, I want to make something clear; I am not against surgery for the right patient. Sometimes, it is not only necessary, but it is an emergency. Surgeons for the most part are highly intelligent and capable human beings. Thank God for these men and women. They can absolutely save lives and they do save lives daily.
I AM however against surgery for the wrong patient. Certainly when research shows us that many of the problems that are ‘fixed’ are not necessarily out of the ordinary and, in the end, may not even be what is actually the source of the pain in the first place. This, when we have been shown to be highly effective in treating these patients safely, conservatively, non-invasively, and without pharmacological means. I am 100% against surgery in those patients.
Here is a hopeful statistic for you; out of approximately 56 million sufferers of back pain, only about 5% of those actually need surgery. That is an impressive stat, folks. There is another research paper by Keeney et. al(Keeney BJ 2013). that came out within the last five years that compared back pain sufferers using surgeons as their first stop in the healthcare system vs. those sufferers using chiropractors as their first stop.
It showed those seeking care with a surgeon first had surgery 42.7% of the time. That is a HUGE number!! But get this; for those visiting doctors of chiropractic first, they only had surgery 1.5% of the time!! That’s HUGE too, wouldn’t you say?
They say if you only have a hammer, everything looks like a nail, right? This paper proved that if you go to a surgeon, there is a high probability you will get surgery. But guidelines and more current research is showing that the vast majority of the time, back and neck pain sufferers DO NOT need surgery.
Research from this year by Harris et. al(Harris IA 2020). suggest that the problem with spinal surgery is that surgeons look at pain as a purely mechanistic issue. Meaning that if they can just cut out this bulging part or that arthritic spur part, then the pain should go away and everyone should be happy. That mentality completely discounts what is termed Yellow Flags and the biopsychosocial aspect of pain.
For example, when a patient is in what is called chronic pain syndrome, and they have a surgery where everything goes perfectly, they still have a 60% chance of developing pain at the new site of surgery. That is because of the part of the pain that the brain plays a part in. Without the brain, there is no pain and in a significant portion of patients, pain does NOT just exist at the place where patients point to their pain.
The easiest way to demonstrate this is in the case of phantom limb pain. For those unaware of phantom limb pain, it is when an amputee still experiences pain in a limb that has been amputated and is completely gone. How is that possible? It is possible because, for chronic pain sufferers, part of the pain lives in the brain and the pain experience is made up of various factors including the patient's beliefs about their condition and their ability to recover, the patient’s level of sensitization in their central nervous system, what they have been told by other practitioners, and their confidence in their treatment going forward just to name a few.
That is the very essence of the biopsychosocial aspect of pain summarized briefly. For a large number of patients, you cannot simply go and cut pain out and sew the patient back up. It doesn’t work that way which is why so many back and neck surgeries have to be repeated countless times.
What about the surgeries themselves? What do we know about that aspect of spinal surgery? Fortunately, the research by Harris and colleagues gives us some clarity in regards to chronic pain patients. It turns out that the most common surgeries for musculoskeletal conditions in chronic pain patients have very little real solid randomized controlled trials behind them. There is little to no research comparing the surgical procedures to patients that had no surgery at all.
Of the 6,735 studies done on these surgeries for CHRONIC PAIN, only 64 (less than 1%) compared the surgery to not having the surgery. Here’s the kicker though; of those 64 that actually did make the comparison, only NINE of those papers were actually favorable to having the surgery! The ENORMOUS majority of papers did not favor having the surgery. To round this discussion out, none of the studies using patient blinding for the procedure found it to be significantly better than not having the surgery at all.
When Is Surgery NOT OK?
Of course, these are generalities and do not constitute medical advice but, in general, the vast majority of non-complicated neuromusculoskeletal pain can and should be treated by an evidence-based, patient-centered chiropractor that is experienced in utilizing a wide array of modalities. Things like spinal manipulative therapy when appropriate, exercise, soft tissue treatment, and acupuncture.
When there is no decrease in muscle function, reflexes, or sensation from one side to the other, then there is usually no need for surgery. It is easy for someone in no pain to say this so this may be an unpopular opinion but, in general, pain is not a reason for surgery. I want to say that again, “Pain is not a reason for surgery.” Remember 56 million sufferers of pain and only 5% actually need surgery.
When your reflexes, sensory, and muscle function is even from side to side, most findings on MRIs like disc herniations, disc degeneration, arthritis, and things of that sort are not reasons for surgery. They ARE reasons for treatment with a conservative practitioner that has experience in getting these types of patients out of pain.
Keep in mind that sciatica or pain into a leg or something of that sort is not a reason for surgery initially. We have been very successful in getting symptoms into limbs to resolve if given the time and the chance.
Beware of new treatments. Many times, patients are desperate to get out of pain and will try any quick fix available up to and including new, unproven techniques. As I have shown, even the established techniques are not typically thoroughly vetted. You can be fairly confident that new procedures are not well-validated too.
When Does Surgery Make Sense?
The most obvious case where surgery is required is when there is trauma. A car wreck, a severe fall, or something of that sort can most certainly be a reason for surgical intervention.
In addition to trauma, another big reason for surgery could be a change in bowel or bladder function or if there is numbness or tingling in the areas of the body that would contact a saddle. That is called cauda equina syndrome. That is surgical and that is an emergency.
Beyond bowel or bladder function difficulties, other neurological issues like
According to a global expert, Stuart McGill, PhD., you should consider surgery when the pain has been unrelenting and severe for a substantial period of time. He says that patients that have been in pain for only 3 weeks and then have surgery have been some of the most disabled post-surgical cases he has experienced before.
He also says to discuss the pain with the surgeon. What is the pain generator and can it actually be cut out? If several tissues are involved, the chances of success go down for sure. If there is damage at several spinal levels, the chance for success drops substantially. You have to consider things like that.
In short, you must exhaust conservative treatment first. Before you ever even consider surgical intervention. That is not simply the opinion of a chiropractor that stands to gain financially but is the opinion of the American College of Physicians. In their report by Qaseem et. al. (Qaseem A 2017), they laid out recommendations for treatment of back pain. Both chronic and short-lived. They are as follows:
First, clinicians and patients should select nonpharmacologic treatment with things such as spinal manipulation, massage, heat, acupuncture, and potentially a non-steroidal anti-inflammatory.
Secondly, for patients with chronic back pain, again, seek nonpharmacologic treatment with spinal manipulation, exercise, acupuncture, cognitive therapy to treat the biopsychosocial aspect, tai chi, yoga, low-level laser, etc.
Thirdly, for those that do not respond to nonpharmacologic treatment, tram ado or duloxetine may be appropriate. Opioids are only an option in patients who have failed all other recommended treatments.
Obviously, the LAST LINE therapies will be epidural steroid injections and surgical intervention. Too many practitioners are trying to keep this dynamic flipped upside down in a dogmatic attempt at maintaining the status quo and maintaining a static income.
Final Thoughts On Spinal Surgery
One of the worst saying known to man is, “We’ve just always done it this way.” And recall, if all you have or all you know is the hammer, everything starts to look like a nail.
The most disappointing part of it all is that chiropractors only see about 10% of the population on average give or take. Think of all of the people we could help. Of all of the patients that didn’t know they should have been given other options that research has proved are highly effective.
You can help by sharing this article with others. Share with them right now so that someone you love that might be scheduled for surgery tomorrow realizes there may be another way.
Because most of the time….there is.
Aha moments are powerful and this article may just be that for someone you truly care about. So do us and your network of people a favor and pass this information along to them. Maybe we can start to turn the tide.
- Harris IA, S. V., Mittal R, Adie S, (2020). "Surgery for chronic musculoskeletal pain: the questions of evidence." Pain 161(9): S95-S103.
- Keeney BJ (2013). "Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State." Spine (Phila Pa 1976) May 15(38): 11.
- Qaseem A (2017). "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians." Ann Intern Med 4(166): 514-530.
Dr. Jeff Williams, DC, FIANM is a Fellowship-trained Neuromusculoskeletal specialist and chiropractor in Amarillo, TX. As an Amarillo chiropractor, Dr. Williams treats chronic pain, disc pain, low back pain, neck pain, whiplash injuries, and more. Dr. Williams is also the host of The Chiropractic Forward Podcast (http://www.chiropracticforward.com). Through the podcast, Dr. Williams teaches fellow chiropractors and advocates weekly for evidence-based, patient-centered practice through current and relevant research. If you have any questions for Dr. Williams, feel free to email at [email protected]Learn more about Dr. Williams and his practice at https://www.amarillochiropractor.com.
Dr. Williams's full-time Amarillo chiropractic practice is Creek Stone Integrated Care at 3501 SW 45th St., Ste. T, Amarillo, TX 79109