A helpful guide for all those confused patients out there
If you suffer from back pain and have exhausted 6+ months of conservative therapies, such as physiotherapy, chiropractic adjustments, medications and injections, then the next step may be to speak with a spine surgeon.
Prior to a consultation, the surgeon or their administrative team will refer you to a Radiology Clinic for imaging to see what your spine looks like, including X-Rays, MRI, CT Scan or other scans. These images will allow the surgeon to look for pathological findings that correlate with your symptoms.
The priority of the spine surgeon will be:
- •Ensure you are safe, that your spine is stable, and that the delicate nerve structures inside and surrounding your spine are not at risk.
- •Ensure you have the best possible quality of life.
Now this is where it can get confusing: More so than any other surgical speciality group in medicine, different spine surgeons might recommend completely different treatment plans, for the same patient, for the same diagnosis, and at the same moment.
5 Reasons Why Spine Surgeons Recommend Different Surgeries
- 1. Where it all began: University and Teaching Professors
University hospitals are places of research, learning and innovation, where surgeons start to develop and hone their surgical skills and patient care experiences. Philosophies, methods, and techniques being taught can differ between countries, universities and between teaching professors, including their own philosophies.
- 2. Extended Training & Further Specialisation
A fully qualified spine surgeon may want to specialise further with fellowships. This may include advanced techniques and skills with different approaches to the spine, such as anterior approach (through abdominal cavity), posterior approach (through the back) or lateral approach (through the side). Each approach has its own unique risks and benefits. The surgeon may attend workshops abroad or even a lengthy fellowship under the guidance of senior surgeons considered ‘experts’ in that area.
E.g. The anterior approach required for lumbar disc replacement requires a great deal of vascular preparation, which some spine surgeons may not have specialised training to navigate. Instead, they may prefer the lateral or posterior approach.
- 3. Available Technologies and their Limitations
This area is highly influenced by government health regulatory bodies, in addition to medical research. One example is The Food and Drug Administration (FDA) in the USA, where the 3rd Generation Artificial Discs are not yet approved to be used in surgery, while they are approved in other countries with an advanced healthcare system, such as Germany, France, Switzerland, the United Kingdom, Australia and Canada.
Another example is the TOPS Facet Joint Replacement System (made in Israel) and used by our German surgeons, which is not approved for use in Australia or New Zealand, even though surgeons from these countries have shown interest in this device.
Before allowing new devices to be used in surgery, government health regulatory bodies will be cautious and will want independent clinical trials that demonstrate both efficacy and safety. This requires finding hundreds of patients with almost identical spine damage, to receive the exact same surgery, with outcomes measured over many years.
- 4. Experience and Confidence
Surgeons may have performed a certain technique only a few times or they may have performed it thousands of times. If they are honing their skills in a new surgical technique, they may be less likely to accept more complex cases, in the best interests of the patient. In those cases, they refer the patient to one of their more experienced colleagues.
One example we regularly observe in medical decision-making is when some spine surgeons consider previous posterior decompressive surgeries (like discectomy and laminotomy) as a contraindication for Artificial Disc Replacement (ADR) due the risk of scar tissue from the previous surgery. According to our spine surgeons in Germany, these same patients can still be suitable candidates for ADR, where around 50% of their lumbar ADR patients already had some type of posterior decompression surgery.
A surgeon will recommend the best surgery for their patient according to their knowledge, opinions, and experience. Questions are welcomed, as are second opinions. Mutual respect is the key to maintaining a solid doctor-patient relationship.
- 5. Surgeon’s Personal Philosophy
Surgeons are not robots. They are real people just like the rest of us, and personal philosophy can play a part in advising for surgery. For instance, a surgeon may feel that you haven’t properly exhausted conservative treatments, and that surgery is not yet indicated.
For example, if the final solution a surgeon can offer is a spine fusion, they may want to try minimally invasive decompression surgeries first (discectomy – removal or disc, or laminotomy – removal of bone). If a surgeon can offer a motion-preserving solution with a new generation implant, then they may prefer to skip the smaller ‘symptom treating’ surgeries and opt for that approach. Patient age, underlying medical conditions, and quality of life are contributing factors.
Another example is an ongoing topic of discussion amongst spine surgeons, with a debate held on the first day of Eurospine’s 2017 Convention in Dublin titled “Lumbar Disc Herniation: Do We Operate Too Early or Should We Operate Earlier?”. Compelling arguments were presented from both sides.
So How do I Know Which Spine Surgery is Best for Me?
From the 5 reasons above, it’s easy to see why spine surgeons can recommend different surgeries. All patients should receive and investigate multiple independent specialist opinions before proceeding with any invasive surgery. This is something we support 100%. Independent means that the surgeons are not affiliated with each other, e.g. Working together in the same clinic or hospital.
Some of our patients even told us that during consultations they did not mention the advice from their previous surgeon consultation, so that they could have peace of mind that they were receiving an unbiased recommendation.
Spine surgery patients must be informed to make the best choice regarding their own healthcare. Other than speaking with multiple specialists, this can include performing their own research, speaking with previous patients, asking the hard questions, and discussing their various options with their trusted personal physician.