Prehab – Optimizing Surgical Outcomes

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Chronic pain is problem that infiltrates every aspect of your life. You have pursued endless treatments with promise of relief and you keep being disappointed. Eventually you may give up any hope of a cure. Most people are not anxious to undergo surgery but it seems like a definitive solution and what else is there to do? Additionally, surgeons are likely to promise a good outcome. Why wouldn’t you choose that option?

Focusing on low back pain, there is a major problem. Surgery for chronic back pain doesn’t work very well. The success rate for most research papers reporting the outcomes for fusion for back pain is around 25% (1, 2) and the data also shows that you can induce or worsen pain after surgery between 20-60% of the time. (3) So the chances of making you worse are higher than the chances of success. So what do you do? Here are some basic concepts to consider.

Surgery is not a “definitive solution”. It should only be considered for a defined structural problem. That is a lesion that can be defined on an imaging study (MRI, Xray, etc.) with symptoms that match the identified structural problem. You can’t fix anything if you can’t identify the problem. LBP is a non-specific symptom and the cause for generalized pain is rarely identifiable. I am clear with all of my surgical patients that whatever arm or leg pain I can solve with surgery; it won’t help your back or neck pain.

Chronic pain is complex and each human being is unique. There is a trend in medicine to recommend simplistic solutions to this complex problem. Many factors affect pain and all need to be addressed simultaneously. Most treatments help pain but none are effective in isolation. The variables include:

  • Sleep
  • Stress
  • Physical conditioning
  • Medications
  • Life outlook
  • Family relationships

Since each person is unique and complex, you are the only one who can solve your pain. You must take control of your care with the medical profession being the source of your information and guidance. If your mindset is, “I just want my pain to go away” or “Fix me” you have almost no chance of meaningful improvement.

 

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What is happening in modern medicine is disconcerting. Providers are almost all on a volume demand where we are given just a few minutes per patient to really figure out what is going on. It is essentially impossible, so we are recommending treatments based on limited information. When you show up in a surgeon’s office, they are going to either recommend surgery or not. A paper out of Baltimore shows that less than 10% of surgeons are assessing the known factors that affect the outcomes of surgery, which leads to predictably poor outcomes. (4)

My wake up call

About six years ago my staff began to notice that patients who were engaging in taking charge of their own care were going through surgery with less pain, better rehab and more consistent long-term outcomes. My approach had been if there was a surgical lesion, I was fairly aggressive in surgical treating them. My thought was that a person in chronic pain couldn’t tolerate the additional harm and discomfort of an identified structural problem. Most patients did fairly well but a significant number were worse after a well-performed procedure for severe pathology.

About that time, I had a patient with tightly pinched nerves in his lower back. He had both back and leg pain. I tried to work with him for a few months by addressing the above-mentioned common sense variables. He wasn’t buying it. I was clear that surgery would not help the back pain but could help the leg pain. Sure enough the leg pain did disappear after I took the pressure off of the nerves and stabilized the unstable level with a fusion. I would have thought that relieving the leg pain would have made a big difference in his overall quality of life. However, his back pain became much worse and he became incredibly angry. When I reminded him about our pre-operative conversation about not relieving back pain, he went ballistic. Then I came across scientific studies about how operating in the presence of chronic pain can induce pain at the new surgical site. I made a decision then that if a given patient didn’t want to learn about the nature of pain and take responsibility for his or her own care, that I was not the surgeon for them. Why would I offer a procedure in a scenario where the success rate was severely compromised?

Current protocol – prehab

For patients considering elective surgery, we want them first engaging in their own healing process for at least eight to twelve weeks. I encourage them to engage for as long as needed. Some will participate in prehab activities for several years. We want them to be:

  • Getting a restful night’s sleep for at least a couple of months. Lack of sleep will induce chronic pain. (5)
  • Actively addressing stress to the point where they feel a noticeable decrease in anxiety and frustration.
  • Defining and stabilizing pain medications. At a certain dose, narcotics cause more pain by sensitizing the nervous system.
  • Becoming more physically active.
  • Educated
    • Understand the neurological nature of chronic pain.
    • Identify whether they have a structural problem that is amenable to surgery? Do they really understand the risks versus benefits?
    • Know that surgery won’t significantly help neck, thoracic or low back pain.
  • Looking at harmful habits.
    • Stop smoking for at least six weeks prior to a fusion.
    • Address eating/ weight
    • Address any recreational drugs being used, including excessive alcohol?

All of these issues affect outcomes. It is not a complete list but it does address the core problems.

What happened?

After insisting on prehab activities, I did lose a significant part of my practice. Many patients would see another surgeon, bypass prehab and undergo surgery. But what happened to my practice was unexpected. Not only was I consistently seeing better outcomes, but dozens of patients with severe pathology were cancelling surgery. Their pain had dropped to the point where it was not worth it to them to undergo surgery with its attendant risks. With so many non-surgical successes if I had to depend just on performing elective surgery on degenerative spinal disorders, my practice would suffer.  I supplement my fewer elective surgeries by dealing with complex fractures, deformities, tumors and infections.

These amazing outcomes were entirely unexpected. I had no idea how powerful prehab activities could be! It is incredibly rewarding to see a patient become free of pain without exposing him or her to the risks of surgery. I have done surgery for long enough that I am well-aware of the fact there is no such thing as, “simple surgery.” Complications and poor outcomes are always unanticipated and no one (both surgeons and patients) thinks it will happen to them. It is also enjoyable to see the patients consistently do well when I do perform the operation.

One important caution – this article is not relevant if you are experiencing neurological compromise such as acute leg or arm weakness, loss of balance or bowel and bladder control. There are situations where emergent or urgent surgery is warranted fortunately usually works well.

Juan

I had an older gentleman who was having difficulty walking because his legs hurt and felt rubbery from tightly pinched nerves in his lower back. I wanted to quickly recommend a laminectomy to decompress these nerves and he would have done well. He also couldn’t read English and I thought the chances of him successfully engaging in the DOC process (prehab activities) were limited. I held the line and he began to use the Back in Control website tools utilizing the Google translator. He kept holding off on doing surgery. He came in six months later for what I thought would be his final visit before deciding on surgery. When I asked him if he was ready for surgery, he started laughing. “What are you talking about? I am walking as far as I want and am out dancing a couple of times a week. My leg pain is gone.”

Variations of his story happen several times every week. If someone decides to deeply engage in the healing process, it is almost always just a matter of time before they succeed. It is the length of time, which is unpredictable. If there are only small improvements, most will eventually experience dramatic relief.

Spine surgery is risky and I would even argue dangerous. It is critical that you take the decision to undergo it seriously and fully engage in every possible option before pursuing it. If your surgeon is not assessing or having someone else look at all the above-mentioned prehab factors, then it is your responsibility to challenge him or her. If there is not a specific identifiable structural problem, the decision for surgery needs to come off of the table. Chronic pain is solvable and surgery when it is appropriate can contribute to a successful outcome. It should never be performed without assessing an addressing all of the factors affecting your pain.

 

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Video: Get it Right the First Time

  1. Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
  2. Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 190
  3. Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
  4. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
  5. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.