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Mir H. Ali, MD, PhD
Orthopedic Spine Surgery
Patient Educational Series

Basics of Spine Surgery

Spine surgery can be made complicated by the variety of medical and surgical terminology, the number of levels of surgery, the possible different surgical options available, and the lack of agreement even among experts. This is all made even more difficult by the medical system, in which more time is spent with a nurse or a physician assistant than with the surgeon and a surgeon who does not/cannot spend time addressing the needs of his/her patient and the patient's family.

I have recently experienced this personally as a family member. My spouse - wife of a surgeon - went to see her Ob/Gyn physician and was signed up for next day surgery in a three minute conversation. The only mention of surgery was, "Let's take a look tomorrow". My wife drove home thinking she was going to drive herself home from this simple procedure. After I showed her the details of the procedure - along with the risks, benefits, and alternatives to surgery - did she decide to postpone surgery and consider her options. She was able to cancel because her spouse is a surgeon and knows that every surgery - so matter how small - comes with risks. Only after one educates himself/herself should a patient consent to undergoing a surgical procedure.

To that end, I have recommended a few general principles to always follow for myself, my family members, and my patients. These are: 1) the patient must fully understand what is being done, what the goals of the procedure are, what are the possible risks, 2) the patient must understand if all non-operative treatments have been pursued, and 3) patients should get a second opinion prior to undergoing surgery. Once these objectives have been met, then the patient should proceed with surgery with a surgeon of his/her choice.

The first principle is important for both the patient and the physician. In a litigious society, many times the patient expects a certain outcome from a surgical procedure and when that expectation is not met, then the patient is disappointed and considers the surgery a failure. However, the surgeon clearly stated to the patient prior to the surgery what the goals of surgery are and what is not expected to improve with surgery.

Nowhere is this more common than in spine surgery and one of the major reasons for spine surgery's poor public reputation. Many times, surgeons perform lower back surgeries to relieve the patient's buttock/leg pain. Relief of the patient's back pain is not a major goal of the operation. However, if the patient is having 95% back pain and 5% leg pain prior to surgery, then perhaps a surgery with significant risks is not a worthwhile endeavor. These expectations are shared and misunderstandings avoided with proper and clear communication between the surgeon and the patient.

While medical terminology can be complex and confusing, it is the responsibility of the patient to understand - in their own words and at their educational level - what is being done to his/her body. It is the job of the surgeon to be able to explain the complexity of the surgery in easy-to-understand terminology so that anyone can understand it. If it does not make sense, the patient should seek another opinion and avoid surgery until he/she understands what will be done. In the end, everything should make sense and only then should one consent to surgery.

Secondly, it is unfortunate that we live in a society and at a time where even doctors' motivations can be questioned. Surgeons make a lot more money by doing surgery than avoiding surgery. Thus, it is not uncommon for surgeons to recommend surgery because it is in their best interest financially. The manner in which medicine is evolving in the US today, doctors and patients are treated like commodities. The doctor has a certain number of operations he has to perform every year to achieve his salary, and the patient becomes a unit or a procedure instead of a person. The medical system is more concerned about your insurance card than it is concerned about your name, your problem, or your medical history.

In spinal disorders, most conditions can be treated or managed without surgery. Rarely is surgery an emergency and those situations are pretty obvious. If someone cannot walk because something is pressing on their spinal cord, almost every spine surgeon in the country would agree that the patient needs surgery to preserve any chance for recovery. If someone has lost control of their bowel/bladder because the nerves to those organs are compressed, almost every surgeon would agree that surgery should be performed as soon as possible to preserve any chance for recovery. Other than these two conditions, surgery can be delayed for at least a few weeks (if not months) in favor of observation, oral medications, physical therapy, spinal injections, etc. If all of these have failed to relieve the patient's pain and/or the patient is getting weaker from nerve compression/damage, then surgery should be considered as a last resort. Before a surgeon recommends surgery, he/she should review all of your non-operative treatment options and make sure that you indeed have tried 'everything under the sun' and they have not worked. Then surgery should be discussed as a final option.

Thirdly, everyone considering surgery should obtain a surgical second opinion. Most people get a number of estimates before the get their car repaired, most people get multiple estimates before remodeling their kitchens, and most people get bids on lawn maintenance for their homes. Why do people hesitate to get second opinions for complex surgical procedures? The conventional wisdom is that the surgeon will be offended by the patient seeking a second opinion. Most surgeons would obtain a second opinion if they were patients and should expect the same for their patients. Most surgeons welcome second opinions in that it confirms for them and the patient that all non-operative treatments have been exhausted and surgery is indeed the only remaining option. A surgeon who is offended by a patient getting a second opinion is either: 1) insecure/unsure about his recommendation or 2) concerned more about his feelings than his patient's. Either way, this is not the type of surgeon most people would want to have taking care of them.

So, if these three principles are followed correctly, then patients and surgeons should have a very good relationship prior to surgery, thus optimizing success in the operating room and following surgery.

Please discuss any further questions about your specific situation with a fellowship-trained orthopedic spine surgeon.

Mir H. Ali, MD,PhD
Director - Deerpath Spine Institute
Orthopedic Spine Surgeon - Rezin Orthopedics & Sports Medicine

Dr. Ali is a board certified orthopedic spine surgeon trained in the diagnosis as well as the treatment of non-operative and operative spinal disorders. Dr. Ali practices in the far western and southwestern suburbs of Chicago and utilizes surgery as a last resort when all other non-operative treatments have failed to relieve pain and/or reduce risk of nerve damage/injury. All recommendations on this site are for general situations and a particular situation requires evaluation before specific treatment recommendations can be made.