One Neurosurgeon's Troubling Trail of Surgeries
- Thread starter Ericokle
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outcomes in spine surgery are skewed. are the patients going to walk out thanking you for turning their life around 100% as in total joints?... no.
does the spine surgeon prevent further degeneration and restore some measure of QOL? yes.
These surgeries get villified because back pain and degenerative spinal disease is a very difficult problem to deal with... Patients are often left in pain, although typically better than before surgery. There are no great solutions, but they are improving with MIS techniques.
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As previously mentioned, patient selection is the key to successful spine surgery. Doing unindicated back surgery results in unhappy patients. Selecting carefully will get good results, with statistically proven outcomes. For example, spondylolisthesis:
Weinstein, et al. NEJM 356(22):2257-2270,2007
i am familiar with that but it has 2 years of followup. hence my couple of years criteria.
also no evidence that it "prevents future deterioration," just that pain and functional status improved for 2 years. I wonder how many of those were reoperated on for failure above the fusion after 2 years.
not hating on fusions, just that they are vastly overdone.
also no evidence that it "prevents future deterioration," just that pain and functional status improved for 2 years. I wonder how many of those were reoperated on for failure above the fusion after 2 years.
not hating on fusions, just that they are vastly overdone.
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As a Physical Therapist, I am completely against a patient having surgery until all other means have been exhausted, unless the situation presents itself where a patient is in urgent need of the surgery to prevent loss of function.
However, with that being said, I would have to say that I agree that many spinal fusion surgeries are unsuccessful, but I do not believe it is due to an unnecessary surgery, or a failed surgery. My belief, is that this patient, in most cases, developed their issues due to a particular lifestyle. Therefore, the performed surgery, if done correctly, has "repaired" the damage done and should limit further damage to those specific tissues.
I believe the biggest problem with the unsuccessful surgeries is the lack of follow-up treatment post-surgery. Each patient should go through a GOOD trial of PT, that involves a significant amount of education regarding this patients particular lifestyle that lead them to the point of surgery, areas of focus that need addressed, and then a very conservative treatment approach that incorporates postural training, core stabilization (avoiding flexion in most cases), LE strengthening as many of these patients are significantly deconditioned, and a very thorough back school educating patients on bending techniques, lifting techniques, proper ways to perform ADLs that would limit/decrease spine loads, etc. All of this would be incorporated in the 1st 6 months following the surgery. Then from what I understand, most patients have a long-term follow-up, 6+ months - 1 year, and at this point in time, have the patient follow-up on the previous treatment involved, education, etc. Then if the patient's fusion was performed due to disc pathology, possibly have the patient go through a very conservative extension program in order to prevent future problems. Obviously this would be excluded in the cases of spondylo or stenosis issues that lead to the fusions being performed.
As a Physical Therapist, one of the biggest issues I see, is that many surgeons do not have a post-op fusion protocol that is to be followed during the rehabilitation process, and the ones that do, usually only involved the 1st several weeks following surgery.
In my opinion, this often leads the patient into believing that the post-op process is not nearly as important, and that the fusion has been performed and they are either "healed" or everything that can be done, has been done.
I'd love some discussion on this, and again, please correct me if I am wrong, or have been misinformed. Again I'm just presenting my perspective as a PT, and would appreciate more insight.
Thanks in Advance,
However, with that being said, I would have to say that I agree that many spinal fusion surgeries are unsuccessful, but I do not believe it is due to an unnecessary surgery, or a failed surgery. My belief, is that this patient, in most cases, developed their issues due to a particular lifestyle. Therefore, the performed surgery, if done correctly, has "repaired" the damage done and should limit further damage to those specific tissues.
I believe the biggest problem with the unsuccessful surgeries is the lack of follow-up treatment post-surgery. Each patient should go through a GOOD trial of PT, that involves a significant amount of education regarding this patients particular lifestyle that lead them to the point of surgery, areas of focus that need addressed, and then a very conservative treatment approach that incorporates postural training, core stabilization (avoiding flexion in most cases), LE strengthening as many of these patients are significantly deconditioned, and a very thorough back school educating patients on bending techniques, lifting techniques, proper ways to perform ADLs that would limit/decrease spine loads, etc. All of this would be incorporated in the 1st 6 months following the surgery. Then from what I understand, most patients have a long-term follow-up, 6+ months - 1 year, and at this point in time, have the patient follow-up on the previous treatment involved, education, etc. Then if the patient's fusion was performed due to disc pathology, possibly have the patient go through a very conservative extension program in order to prevent future problems. Obviously this would be excluded in the cases of spondylo or stenosis issues that lead to the fusions being performed.
As a Physical Therapist, one of the biggest issues I see, is that many surgeons do not have a post-op fusion protocol that is to be followed during the rehabilitation process, and the ones that do, usually only involved the 1st several weeks following surgery.
In my opinion, this often leads the patient into believing that the post-op process is not nearly as important, and that the fusion has been performed and they are either "healed" or everything that can be done, has been done.
I'd love some discussion on this, and again, please correct me if I am wrong, or have been misinformed. Again I'm just presenting my perspective as a PT, and would appreciate more insight.
Thanks in Advance,
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The thing with fusions is that if the bone does not fuse, the hardware will fail within 1-2 years. If a bony fusion occurs, a pseudoarthrosis will never develop, because the hardware is essentially no longer being used. Therefore the fusion and increased QOL is lasting.
I agree that fusions are overdone, that's why we have to develop real criteria for when to fuse. The guidelines are already there that fusion for degen disease without spondy or instability is not generally indicated except in 'special' circumstances.
