Based on the principles I have learned through the DOCC Project, I would propose the following definition of “failure of conservative care.”

“Failure of conservative care” is defined as ongoing pain after successfully treating the central nervous system and the soft tissue components of a medical case. In the case of an identifiable structural lesion, surgery would be a reasonable option. Surgery is NEVER indicated in the absence of a structural lesion.

I am going to outline what I feel is my personal standard of non-operative care:

• You should be experiencing full restful night’s sleep for three months
• Effective stress management tools should be in place and functional. You are able to effectively deal with your stress.
• Physical therapy should be combined with an aggressive self-directed conditioning program for at least six months. If there is a structural problem, the soft tissue component should still be maximally treated.
• Some structural lesions are compelling enough to require surgery first
• Medications should be used to effectively treat the symptoms of insomnia, pain, and sometimes anxiety. They should be used on a short-term basis to allow you to maximize your function.
• Have specific goals in place from the very beginning of treatment
• Education—you have to personally become educated regarding the issues regarding chronic pain, rehab, and outcomes of surgery.

Using the above criteria, most patients with soft tissue pain choose not to undergo any surgical procedures.

Note that I do not feel surgery should be attempted, even if all of the above criteria are met, if there is not an identifiable source for your pain. If I cannot see it, I cannot fix it.

You are the one who has to take responsibility for the above criteria being met. A surgeon cannot get inside your head. We base our decisions upon our own filters and what you are saying. It is common for me to hear a patient say, “If I only knew how difficult the surgery was, I wouldn’t have had it; my pain was not severe enough to undergo any surgery.”

BF