Improve Your Odds of Good Surgical Outcomes with Spine Surgery

Saturday, May 19, 2007 | 0

By Dr. Zoran Maric

Lower back injuries are the most common type of work-related injuries. A large percentage of health care resources are spent on treating these injured workers. Many eventually have spinal surgery.

Many of these patients do not do well. How many times have we seen patients have surgery and continue to complain of pain, continue to take narcotics, and never go back to work?

Unfortunately, I see it all of the time.

At times, it seems that it is the luck of the draw that determines how well a patient does with surgery. It does not need to be this way. There are ways to improve your chances of getting a good surgical outcome.

Here is an example of a recent patient that came through my office as an independent medical examination:

The individual was an 18-year-old male when he was injured while working on June 27, 1996. He weighed 320 pounds at the time. He had diffuse back and leg complaints. His MRI showed a disc bulge at L4-5. His clinical examination was negative. He subsequently had four operations.

The first operation was a laminectomy at L4 and L5. It did not help his pain.

The second operation was a laminectomy and fusion from L4 to S1. It did not help his pain.

The third operation was a repeat fusion. It did not help either.

The fourth operation was a laminectomy of L3 with fusion up to L3-4. It did not help his pain. It was unfortunately complicated by an intraoperative myocardial infarction (heart attack) and hypotension. This resulted in anoxic encephalopathy with a permanent brain injury.

He is now a 27-year-old gentleman, who is disabled, is narcotic dependent, and has a permanent brain injury with a damaged heart. This did not need to happen.

The first operation was not medically indicated. He had surgery for perceived abnormalities that did not correlate with his subjective pain complaints. He has been unfortunately disabled by his medical community at a very young age.

So what happened here?

The patient went to an aggressive surgeon instead of an objective, conservative surgeon. This patient should have been treated conservatively and returned to work. That would have been in his best interest. Instead, his life basically has been ruined at a very young age. This could easily have been avoided.

We have to keep in mind that most spinal surgery is "elective." Nothing bad happens if you do not have spinal surgery. It is, therefore, imperative to objectively evaluate these patients and their diagnostic studies. It is extremely important to treat the patient and not the films.

As we know, MRI scans frequently show abnormalities that are of no clinical significance.

For example, over one-half of normal asymptomatic people have at least one disc bulge. Two-thirds of normal asymptomatic people have at least one so called "annular tear." If you see these findings in the report of an injured worker it means absolutely nothing -- unless you are looking for excuses to operate.

So, how do we improve our odds of a good surgical outcome?

It turns out that the doctor you refer the patient to determines how well your patient will do. It has very little to do with the skills of the surgeon. It has everything to do with how objective the doctor is and how aggressive he is when it comes to spinal surgery. Most surgeons can do the surgery correctly.

Many surgeons have difficulty objectively evaluating the patient and determining whether the patient is an appropriate surgical candidate or not.

Here is a list of the type of doctors to avoid:

* Recommends surgery on the first visit

* Recommends surgery without conservative treatment

* Prescribes narcotics for prolonged periods of time

* Recommends the same testing and same type of surgery for every patient

* Recommends new or investigational surgery (artificial discs, Dynesis, etc.)

* Frequently performs multiple operations

* Has even one disaster patient (like the one described earlier in this article)

* Recommends surgery based on discography (it has been shown to be unreliable)

* His/her patients frequently go for independent medical examinations (usually indicates that the patient's are not doing well)

If the patient is seeing one of these type of doctors, I would strongly encourage an independent medical examination before the patient has surgery that may not be in his or her best interest.

The goal with these patients is to relieve pain and restore their function so that they can continue to be productive members of society.

The goal is not simply to do surgery regardless of the outcome. We should not simply accept these poor clinical outcomes because they are "work comp" patients. They can do well with surgery if it is done under the right circumstances.

This column first appeared in The Examiner, a publication of the Arizona Workers' Compensation Claims Associations.

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