My surgical decision-making has become a clearer over this last couple of weeks – but in an unexpected way. I have noticed this year that many patients with significant structural anatomic problems will improve or resolve their symptoms without surgery after engaging in a self-directed structured approach. It appears that as the nervous system calms down that the pain threshold rises.
The barometer I use before I help them make the final decision is whether they are sleeping well and their anxiety levels have dropped under a 5 on a scale of 10. My experience with performing surgery on a patient with a “fired up” nervous system has consistently been less than satisfactory. Pain control is difficult and even the longer-term results are marginal. There is often still a significant amount of residual pain.
I recently saw four patients that I had an almost word-for-word conversation with regarding their decision to undergo surgery. All were men between the ages of 45-65. They had leg pain originating from an identifiable problem in their spine. The pain was severe enough that each wanted to have surgery but they were all at least an 8 out of 10 on the anxiety scale and were not sleeping well. Their stresses included a seriously ill children, loss of jobs, marital problems, etc. and none of them were coping that well.
Can you live with your anxiety?
They were familiar with the DOC project but had not engaged with the concepts at a meaningful level. They were coming back for their second and third visits. Finally I asked each of them the same question, “What would it be like if I could surgically solve the pain in your leg but the anxiety you are experiencing would continue to progress over the next 30 to 40 years?” Their eyes widened with a panicked look and every one replied, “That would not be OK. I could not live like this.” Each of them also grabbed his leg and asked, “Won’t getting rid of this pain alleviate my anxiety?” My answer was “No.”
Neurophysiologic Disorder (NPD)
Anxiety is also a neurological pathways problem and a core symptom of the Neurophysiologic Disorder (NPD). Chronic pain is a huge stress and reinforces permanent anxiety circuits. Although relieving pain may temporarily decrease anxiety, it will remain a significant long-term problem. There are too many other life situations that fuel anxiety.
I told them that although I would love to get rid of their leg pain with surgery my bigger concern was their severe anxiety and possibly chronic pain. I recalled my 15-year battle with pain and anxiety. I was on an endless quest to find the one answer that would give me relief; especially for the anxiety. I also remembered the intensity of that need. At that moment I realized that each of these patients felt that by getting rid of the pain they could lessen or solve their anxiety.
It is actually the opposite scenario. As your anxiety resolves it is common for pain to abate. Crippling anxiety is a solvable problem with the correct approach. That does not include surgery. Also, after a failed surgery, another level of hope has been taken away.
Can you live with your leg pain?
Then I asked each of them that if I could resolve their anxiety but they would have to live with their leg pain, what would that be like? Although not completely happy about the scenario they thought they could deal with it. It was more palatable than experiencing no improvement in their fear.
“Let’s do the surgery first”
My concept of pain has been turned upside down over the last year as I have seen a number of patients who had a tight compression of nerves in their lower back or neck with severe arm or leg pain. I have historically thought that I should surgically solve the problem and deal with rehabilitation later. I felt it would be difficult for them to engage in meaningful non-operative care while in so much pain. Video: Get it Right the First Time
“No” to surgery
These patients did not want to jump to surgery and wanted to give the DOC program a try. Within six to twelve weeks their pain disappeared or subsided to the level where they were not even considering surgery. Although I know pain and anxiety are linked circuits I had never realized that for many patients the pain relief they asking for was for peace of mind.
Conversely I have many patients over the years have a successful surgery for a severe structural problem with no improvement or worsening of their pain. Now I understand. “Neurons that fire together wire together.” Pain, anxiety, and anger are tightly intertwined. As long as the anxiety/anger pathways are fired up they will keep the pain circuits firing. There is also research that shows there is a 40% chance of inducing chronic pain as a complication of any surgery and it can become a permanent problem 5-10% of the time. (1) One of the risk factors is having surgery in the presence of pre-existing chronic pain.
Surgery may or may not help your arm or leg pain. It rarely solves neck or back pain. It really doesn’t work for anxiety. What relief are you asking your surgeon for?
- Ballantyne J, et. al . Chronic Pain after Surgery or Injury. IASP (2011); 1-5.