I saw a 73 year-old woman who came to me for a second opinion.  She had undergone a spine surgical consultation and had been told that she needed to undergo an eight level fusion of her spine from the tenth thoracic vertebra to her pelvis.  She was understandably apprehensive.

She was moderately physically active but not in great physical shape.  Her career had been in the National Guard and she had been able to retire early.  Golf was her passion.  Two years earlier, she had developed pain down her right leg and weakness of the muscles that elevated her foot.  The term commonly used to describe this condition is “foot drop.”  A surgery was performed in the South between her lumbar 3-4 and 4-5 to take the pressure off of the nerves.  The surgery is called a laminectomy. Her leg pain quickly resolved. However, the damage to the nerves in her foot was permanent and she wore a brace to keep her foot from flopping.  Usually foot drop does not resolve with any surgical procedure, as the damage has occurred within the nerve.

Her symptoms were now just a persistent foot drop.  She had no back pain or leg pain.  Her spine was completely straight.  She was able to walk easily with the brace on her lower leg. I looked at her new MRI scan and it showed that the surgeon had successfully taken the pressure off of the nerves to her foot.  There was generalized arthritis, but there is no correlation with spinal arthritis and back pain.  But this is besides the point: she had NO back pain!

You must be asking yourself, “Why does she need another surgery?  The nerve is permanently damaged (surgery will not help) and she’s not in any pain.”

You are correct. My recommendation was that no further surgery should be performed.

I am going to expand on this situation to explain the implications of going forward with a T10 to pelvis fusion:

• This is an operation that can take up to 10 hours to perform
• You are in the hospital for a week
• The fusion takes about four months to heal
• Your strength does not return for at least six months
• The complication rate is over 70% with a significant chance of major problems.  They include: infection, paralysis, hardware failure, blindness, screws damaging nerves, blood clots to the lungs with the potential for death, etc.
• The cost of this operation for society is over $100,000.
• With her spine fused from her lower thoracic spine to the pelvis, she will lose much of her ability to twist (her golf game is finished), and it will be more difficult to bend over. With a fusion, you lose all flexibility in that area of the spine.
• There is a chance that a fusion of this magnitude will cause long-term back pain.

I could go on for a while about the downside of this operation.  I know a lot about it, as this is an operation that I frequently perform. There is hardly anything more satisfying than giving back a person the ability to be completely upright.  However, over my 25-year career I have gone through every possible complication with my patients.  Eventually, we usually end up with a good result, but it always feels like we are waging a battle. There are also those with significant residual problems.

I am very clear about the risks of surgery, not for medical legal reasons, but for them to understand the degree of commitment required to undergo it. The benefit has to be worth the risk.  The only reason I perform an operation like this is for tumor, infection, fracture, or if a patient is bent over and cannot stand up.

In this patient’s situation the risk is high and the benefit is zero.

BF

I would like to clarify an issue.  Essentially every patient I see that has been off work more than three months has elevated anxiety. This is noted on my intake questionnaire or it will come out in conversation.  I always directly address their anxiety.  If I had a choice, every patient would have some access to education, support, and the tools to diminish their stress.  The system can do only so much to decrease their stress, as just the potential of loss of employment is a huge stressor.  It has been mentioned that questionnaires are not adequate to assess anxiety.  From my perspective, I am not sure what an appropriate alternative would be.

What is anxiety? Here’s one definition:

• Feeling of worry
• Something that worries somebody
• Strong wish to do something
• Extreme apprehension

I tried to look up anxiety on Google Scholar this morning.  I could not find a clear definition.  I finally just went to the dictionary and pulled off the one above.  I looked at the first part of the DSM manual  (the manual defines mental health disorders) and am now curious as to exactly what diagnosis I would make from my orthopedic perspective to enable mental health support to be provided to an injured worker.  More importantly, what would a claims examiner use to “buy” a diagnosis?

In which Axis does the diagnosis of anxiety have to be to made (there are five levels)?  Anxiety is part of essentially every Axis I diagnosis.  What anxiety diagnosis has to be made to fulfill the criteria?  (Axis I is the level that the major diagnoses are made, such as depression, ADHD, anxiety disorders, addictions, etc.)

Axis IV is “Psychosocial and Environmental problems.  Here are a few of the Axis IV choices:

• Occupational problems
• Problems related to the social environment
• Problems with primary support group
• Educational problems
• Economic problems

An injured worker has most of these issues.

Every human being experiences anxiety. In turn, it is increased by Axis IV issues. Does that not qualify one for assistance?

If a person has a diagnosable pre-existing anxiety condition, it is unlikely that it would have already been a diagnosis that an injured worker is carrying around.  If a mental health professional makes the diagnosis after the person has been in the worker’s comp system for awhile, then it is impossible to really sort out what is going on.  The Axis IV issues become a major factor.

So when is worker’s comp supposed to provide mental health services?  If there happens to be a pre-existing condition, then it is a major obstacle in return to function and it would make financial as well as humane sense to treat it.

If the anxiety, etc. is caused by the stress of the claim then worker’s comp should cover it, as the injury was the cause of the person’s emotional distress.

Axis III is the Axis where the general medical conditions are listed that can directly or indirectly affect an Axis I diagnosis.  If there is a direct cause and effect then the Axis III diagnosis is also listed in Axis I.  One can make a strong argument that there are multiple musculoskeletal diagnoses that cause a significant increase in anxiety and should be put under Axis I.  The DSM should take the adversity experienced by the injured worker into account. Unfortunately, it most likely does not.

I am going to purchase the DSM book today.  I would like to ask the roundtable to provide me with the criteria needed to obtain mental health support for an injured worker. At this moment, I have no idea.

BF

Advertisement by Roy Carey, a well respected spinal surgeon in Melbourne. This advertisement helped reduce the frequency of spinal surgery in Victoria, New Zealand.

BF

Here’s a checklist that will help you keep track of your progress through the first phase of the DOCC Project.

Step 1—Nail Down Diagnosis

____Feel that you understand whether or not there is a structural problem

____Take the test for the Mind Body Syndrome

____Understand the soft tissues—“Eight Steps to a Pain Free Back”

Step 2—Write

____Free writing

____Read the first third of “Feeling Good”

____Write in the “three column technique” of “Feeling Good”

Step3—Learn Why Writing is Effective

____Read “The Talent Code”

____Read “The Seed of our Undoing”

____Understand “reprogramming” the nervous system

Step 4—Sleep (#1)

____Learn how sleep affects pain

____Sleep hygiene

____Medications

____Stress management at bedtime

____Consider sleep disorders

Step 5—Learn DOCC Principles

____Read DOCC outline

____Read the full or condensed draft of “Back in Control”—use it frequently as a reference

____Commit at least 30 minutes a day to learning about chronic pain—Schedule it!!

____Subscribe to the website

• Do not rush through any of these phases
• Read all of the links of phase I
• Actively engage in the protocol—you cannot improve by just reading
• Print this worksheet and use it to monitor your progression
• Practices you put into place will be ones you will be using the rest of your life
• Your spouse or partner must also fully engage—just have he or she use the word “stress” instead of pain

NH, BF

I talk about the importance about finding the “source” of the pain and the implications of the “real” success rates of most spine operations. This clip takes a closer look into back fusions and the research behind them.

BF

I talk about the lack of awareness to the alternative approaches in the spine surgeon world and the treatment of chronic pain.

BF

“Back In Control” is my book about the DOCC Project. This video is an introduction to the DOCC Project, which is a pain management program to get your pain back In control.

BF

Marsha was a 36 year-old businesswoman with two young children. She was referred to me by another patient and came to see me from the east coast. She had the spontaneous onset of back pain about eight years ago. Everything possible had been tried, but she continued to spiral downward with increasing pain.

In 2005, she had an MRI scan done that showed some mild degeneration of the discs in her lower back. These were normal for her age. A surgeon recommended she undergo two artificial discs at L3-4 and L4-5. They did not help her pain, and in fact, she got worse. The discs buckled, and a year later, they were removed at another hospital on the west coast. During this operation, they went back in through her abdomen to remove these artificial discs. In this situation, the major blood vessels are scarred down and attached to the discs. It is a very difficult procedure, and during the operation, her major vein, the vena cava, was torn. Her ureter (tube from the kidneys to the bladder) was also torn. Both were repaired, but she was left with residual swelling of her feet due to the partial disruption of the vena cava. A year later she had L5-S1 fused for ongoing low back pain.

When she saw me, she still had ongoing low back pain, thoracic pain, and neck pain. Two other spine surgeons had recommended to her that she should undergo a two-level fusion in her neck. Her MRI of her neck was normal for her age showing just some mild degeneration.

She desperately wanted to go back to work. Her husband was threatening to leave her. She was on drugs to wean her off narcotics but was having a difficult time. She was extremely motivated to get better but completely trapped by her pain and lack of a plan to solve her pain problem.

None of her surgeries were helpful or necessary. Yet the spine world was offering her only more surgery. I do not know the end of this story. I spent a couple of extra hours with her explaining the DOCC protocol to her in detail. She is fully engaged and I do think over 12-24 months she can become pain-free and functional. It is upsetting to me that she does have the three-level fusion in her lower back and residual swelling in her feet. If she had been able to engage in the structured rehab before any surgery, she might have completely come back to normal. Now she will have some permanent structural limitations.

BF