When not to operate?

18 August 2008 BACK PAIN AND SCIATICA

Low back pain is common, and  pain originating in the back, but felt in one or other leg, is not rare.

The leg pain is, often loosely and unspecifically, called “sciatica”.

Occasionally surgery has to be performed, and when that is the case I have no hesitation in doing this. That, after all, is how I earn my living.
However in many cases the pain can be resolved by non-surgical ways, utilising the body’s remarkable capacity to heal. One problem is that this might take a number of days or weeks.

Many times in my career I have had patients who have been impatient, returned to their family doctor who said something like this:
“Well we have to get a scan. I can’t understand why the specialist didn’t have a scan. That will tell us what the matter is”. The reality is that the scan often does not advance the diagnosis and its most useful role is as a street map for the surgeon. Therefore there is often not much sense in obtaining a scan unless surgery is contemplated. However, the conversation continues later like this:
“Well there you are, the scan shows you have a disc! I am now going to send you to another surgeon who will take your disc out.”

This is a sad story, but one often repeated. Because an abnormal disc is shown on the scan does not mean that it needs to be taken out. If groups of normal, everyday people were to be scanned many would be shown to have “slipped” discs, which do not trouble them in any way. I have often seen people have their so called “slipped disc” removed, only to find that the pain continued, because it was not coming from that seemingly obvious site at all.

There are times in which removing a disc surgically is imperative – particularly if the symptoms are getting worse or if there is loss of bladder control. But it is always worth attempting a period of conservative management, even if this does take several weeks.

Spinal surgery can go horribly wrong, particularly when undertaken by people who do not spend most of their time doing spinal surgery. If it does go wrong, it is usually irreparable, and the tragic consequences can continue forever.

I have had many patients in my career, who were doing well on conservative management, improving slowly, with every prospect of a full recovery. Instead, they were hustled, either by themselves, their know-all family, a family practitioner, or a surgeon into having some form of surgery, which then went tragically wrong.

After giving advice about non-surgical treatment at times these patients have concluded that I was not interested in them, or afraid or unable to perform the surgery, and have gone to a surgeon who “knew how to do the operation“.

In spinal surgery, more than any other aspect of orthopaedic surgery, the following maxim applies: Good surgeons know how to operate; better surgeons know when to operate; the best surgeons know when not to operate.