Why patients don’t get better after spinal surgery (it’s not always my fault.)

Ok.  I’m going to admit this for you right here and right now: my patients don’t always get better after surgery.  It’s a crazy thought, I know.  But it’s true.  Despite my best efforts to control all variables to ensure that things go smoothly, things can go awry and the patient doesn’t get better (and sometimes gets worse).  Generally speaking there are two categories of variables that must be managed to ensure success in spine surgery.  First, there are the variables that are dependent on me, the surgeon.  These variables stem from the technical, physical and psychological challenges of spine surgery.  I have to correctly diagnose the patient; I have to know the anatomy and technical nuances of the surgical procedure; I have to plan for the patient-specific anatomy of the case; I have to get a good night sleep before my OR day so that I can focus on the case; I have to maintain a level of fitness in order to handle the physical demands of surgery (yes, spine surgery can be quite physically taxing), etc.  No problem.  This is what I signed up for and I’m up for the challenge.  I can manage these variables better than most.  I do want to say one thing about the psychological stress of these cases.  I want every one of my patients to have the best possible outcome.  That itself weighs on my psyche enough.  But when things don’t go as planned and a patient has a poor outcome (I feel as if I hurt them) it can take months for my conscience and confidence to recover.   This isn’t a therapy session though.  I love what I do and overall I think that I handle the stress of it pretty well (my wife is blocked from posting comments on Spinal (con)Fusion, by the way.) 

Here’s what drives me crazy about taking care of spine patients though.  I can control all of the variables on my end and execute perfectly and the patient STILL doesn’t get better.  There isn’t always a direct correlation with my success in the OR and the patient’s outcome.  Why?  Patient-dependent variables, which often are out of my control, also affect outcomes in spine surgery.   Here, I offer a few of the ways patients don’t hold up their end of the doctor-patient relationship.

1)  Patients don’t want to get better.  Ok, so this is a very broad and potentially very damning characterization of some patients.   You could say obese patients or smokers don’t have the discipline to better themselves and thus don’t want to maximize their chances of success after spinal surgery.  As tempting as it is, though, we can’t blame patients for being obese or for smoking.  Both of these are diseases that many patients are incapable of managing on their own.  So while I do think patients in this country should take more responsibility for their own health, we shouldn’t automatically assume that they don’t want to get better because of their weight or their bad habits.    

What I’m referring to here is a more pernicious subset of patients who are actively trying to not get better, the landmines in the minefield that is my clinic.  These patients usually have some sort of secondary gain that they’re after that leads them to consciously or subconsciously fail to improve after surgery.  Maybe they were injured on the job and want to live off of a worker’s compensation claim.  Maybe they don’t want to be in the military anymore.  Maybe they were in a car accident (not their fault) and their lawyer is telling them they can get more money if they appear more severely injured.  Maybe they want more attention from their spouse.  Maybe they just want oxycodone.  You wouldn’t believe what I’ve seen.   And before you come after me for being insensitive, check the literature.  There are dozens of studies correlating secondary gain with poor outcomes in spine surgery. Thankfully as I’ve moved along in my career I’ve gotten better at spotting patients like these and will avoid ever offering them surgery.  That’s the art of spine surgery.

2)  We aren’t good at accurately measuring if a patient is in fact better.  In spine surgery we rely on patient reported outcomes (PROs) measured before and after surgery to assess the patient’s response to the surgery.    PROs generally fall into two categories: those that measure pain severity and those that measure level of disability.   The visual analog scale (VAS) is the most common tool used to assess a patient’s pain level (see figure 1).  In this scale the patient is asked to rate their back or leg pain on an 11-point scale where 0 is no pain and 10 is the worst pain imaginable.  While VAS is useful on a superficial scale, I find that patients’ responses are widely variable thus making the test unreliable.  I frequently will see that a patient has rated their pain a 10/10 on their intake paperwork but when I walk into the exam room they’re sitting comfortably reading a book.  If this is how the patient self-assesses their pain how can I know for sure that the patient in fact got better?  The problem is that pain is so subjective and influenced by so many factors that it’s just hard to quantify objectively.     

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Figure 1: Visual Analog Scale (VAS) for reporting pain. 

Common measures of disability include the Oswestry Disability Index (ODI) and the Short-Form 36 Health Survey (SF-36).  Both of these are quite thorough but again are subject to variability.  The ODI, for example, asks the patient to rate their quality of sleep, sex life and social life.  In my opinion, these are things that are open to wide interpretation (you ask someone about this stuff on a Friday versus a Monday and the answers may vary!).  With so much variability in patients’ responses on VAS and ODI it can be difficult to determine to what extent the patient actually improved after surgery.  Obviously these PROs leave room for improvement.  These days we’re finding that by combining several PRO modalities we can get a more accurate representation of a patient’s progress.

3)  Patients don’t remember how bad they were and thus don’t realize that in fact they’re better.  Recall bias is a well-known entity in medical research.  When asked to recall facts or conditions in the past, research subjects are notoriously inaccurate.  The same applies to spine patients.  A 2017 study out of the Mayo Clinic found significant limitations in how well patients recalled their preoperative VAS scores when asked to recall them a year later. (Aleem et al, 2017)  Also, more than 40% of patients couldn’t remember if it was their back or leg that hurt them more before surgery.  How can a patient tell me if they’re better after my surgery if they don’t remember what was hurting before the surgery. 

Along the same lines, patients may have improper expectations about their surgery and thus may be disappointed in their outcome even when it’s a good outcome.  For example, often patients with lumbar stenosis and spondylosis present with both back and leg pain.  When I consent them for surgery I explain to them that the minimally-invasive laminectomy that I’m recommending will only relieve their leg pain (by fixing the stenosis) and not their back pain.  Some patients don’t hear that though.  After surgery they’ll come back in and tell me that surgery didn’t help them at all.  The exchange goes something like this:

     Me: “Mr. Smith, you’re two weeks out from your laminectomy.  How’s it going?”

     Mr. Smith: “Horrible.  Surgery didn’t help me doc.  You said you were gonna fix me but I’m no better.”

     Me: “Oh no! Tell me where you hurt?”

     Mr. Smith: “My back hurts, Doc.  You said you were going to help my pain.  What happened?”

     Me: “Well how do your legs feel?  Prior to surgery you told me that you couldn’t even walk to the mailbox because your legs hurt so badly.  

     Mr. Smith: “My legs?  Oh they’re great.  Leg pain was gone when I woke up from surgery.  I walked 2 miles this morning. But my back still hurts.”

     Me: (internally) Sigh

I understand why some patients may not fully absorb what I’m telling them.  They’re scared and distracted when the prospect of surgery becomes a reality.   Prospective patients should be mindful of this, though, and make every effort to listen to and process what their surgeon is telling them.   On my end I’m working on ways to ensure that patients hear what I’m telling them so that they can have accurate expectations about their surgery.  This includes detailed handouts discussing surgery as well as audio/video recordings of preoperative conversations that the patient can refer back to when they’re home with their families.  The most well-informed patients will have the most accurate expectations of surgery and thus are most likely to report that they’re better after surgery.

4)  Patients just don’t get better.  Unfortunately some patients, through no fault of their own or the surgeon, just don’t get better.  As much as we like to think we doctors know everything, we don’t.  I think that we just don’t understand every etiology of back pain.  Is it the degenerated disc?  Is it the facet joint?  Has the brain just learned the pain?  There’s just so much we don’t know.  We do our best to make an accurate diagnosis, assess the patient and prescribe an accurate treatment and yet sometimes even that’s not enough for the patient.  This may be the most frustrating thing about what I do.  All I can do is look at myself in the mirror in the morning and swear that I’m just going to do my best for my patients.  Hopefully it’s enough. 

Ok so maybe there wasn’t much technical information in this post.  That’s OK.  Hopefully by hearing my candid thoughts on the matter you’ll be better equipped when talking to your surgeon about the surgery he’s recommending.  Ultimately I love taking care of my patients and just want them to have the best possible outcome after their surgery.  We’re in it together.  If we both do our parts you, the patient, are going to do fabulously after your surgery.   

 

Thanks for reading!

J. Alex Thomas, M.D.

Sources:

Aleem IS, Duncan J, Ahmed AM, Zarrabian M, Eck J, Rhee J, et al.: Do Lumbar Decompression and Fusion Patients Recall Their Preoperative Status? Spine (Phila Pa 1976) 42:128–134, 2017.