By: Dr. Warren Wulff
So, you’ve been referred to a spine surgeon. Now what? Relax! Chances are you won’t be leaving the office with a surgery date in hand. Only one in twenty new patients coming to my office is a candidate for an operation. Read on to find out why.
When first visiting the office of an orthopedic spine surgeon like those of us here at Syracuse Orthopedic Specialists, you may be anxious about the possibility of being recommended for spine surgery. Or, not being recommended for surgery in some cases. In this article I hope to shed some light on the process by which orthopedic specialists use to evaluate patients for the potential need of surgical care.
Like most of the doctors here at SOS, I have an academic affiliation and therefore I have responsibility for teaching residents and medical students. When they are by my side in the office, we often discuss whether a particular patient would be suitable for surgery or conservative care. Through this process of teaching over the last 20 years, I have developed a set of three questions which I give to residents. I believe the questions would also be helpful for patients to read and understand. Here are the three major guidelines that I have developed and use when determining whether to offer a patient surgery.
1) Does the patient want the operation?
No one is going to coerce an unwilling patient to have surgery against their will. This may seem simplistic, but it’s discouraging how often we see patients referred here that do not know they are being seen by a surgeon for the purpose of surgical consultation. Patients will sometimes say, “I would never consider having a back operation.” Understandably this results in disappointment and frustration, so we endeavor to set expectations before arrival in the clinic. In part, the responsibility for this lies with the referring physician. There is no substitute for clear and accurate communication between doctors and patients. If a patient does not wish to consider surgery as a potential option for their problem, then they will likely be directly referred on to other providers who specialize in more conservative options. Examples would include physical therapists, chiropractors, physiatrists, pain management specialists or the primary care physician.
2) Is the patient healthy enough to have an operation?
Any surgery carries a certain element of risk and potential for serious complications. When a surgeon and patient consider a surgery, the possible benefits of the procedure need to be carefully considered relative to the potential risks associated with it. In some cases, the surgery is required to save a life or prevent serious health problems. For those instances, we sometimes tolerate a high level of risk. For more elective procedures, we strive to first optimize those patient factors which can be modified to reduce preoperative complications. Over the years a defined set of patient risk factors for poor outcomes from surgery have been developed. Some of these risk factors are fixed and others are modifiable. Through understanding of the nuances of patient specific circumstances, we can often predict the chances of successful or poor outcome from surgery and weigh that against the risk of not doing surgery at all.
After surgery has been offered, most patients will be asked to see their primary care physician (PCP) for medical clearance. It is then up to the PCP to send us a letter indicating that you are “clear” for surgery. In some cases, obtaining clearance is just a simple chart review based on prior visits with your doctor. In other cases, the clearance is more complex involving further testing and visits with other specialists. Without “clearance” from your PCP we cannot offer you an operation. Having medical “comorbidities” such as diabetes, asthma, heart disease, kidney disease, etc. does not mean that you can’t be cleared for surgery, but in many cases the management of those conditions needs to be optimized first. This is one area where you, the patient, are in complete control of the process.
In addition to the requirement for medical clearance, SOS (and most other orthopedic practices) have strict additional evidence-based criteria for elective surgery scheduling. We know from a national database of large groups of patients that certain patient factors are associated with poor outcomes from surgery. Because of this, the American Academy of Orthopedic Surgeons and the North American Spine Society have developed clinical treatment guidelines for us to adopt and follow in efforts to improve patient outcomes from commonly performed spinal procedures. If a patient has health parameters which are outside the recommendations, then elective surgery is postponed until the criteria can be met.
Here are some examples of the more common “Hard Stops” for surgery:
- Diabetic control:
For people who suffer from diabetes tight control of blood sugar levels is critical to their health. Poorly controlled diabetics have a higher than normal risk for surgery complications such as infection and poor wound healing. The hemoglobin A1-C blood test is an indicator of how well someone has been controlling their diabetes over the last 2-3 months. A normal A1C level is less than 6%. A level greater than 8% is the cutoff for elective surgery at SOS.
People who are significantly overweight tend to have increased complications and poorer results from surgeries. Part of this is due to the associated health conditions common to overweight patients, but we have found that the complication rates return to average with sufficient weight loss before surgery. Therefore, at SOS, patients who have a BMI of greater than 40 are not eligible to receive elective spinal surgery. Here’s another area where you can control the process. The negative impact of obesity on surgical outcomes is reversible with weight loss.
When surgery involves spinal fusion, we have abundant evidence to show that the fusion rates and outcomes in smokers are dramatically inferior when compared to those who do not smoke. If a smoker stops smoking prior to surgery and does not smoke for 3 months afterwards, the results are nearly the same as nonsmokers.
At SOS smokers are required to quit smoking and pass a nicotine test before being scheduled for spine fusion surgery. This is yet another area where you can improve your own chance of successful surgery. See the pattern?
3) Would the patient benefit from spine surgery?
This is the hardest question to address and understand, but suffice to say, only your spine surgeon can tell you the answer. Often patients are sent to us from another clinician with the understanding that they will be fixed by surgery. While sometimes correct, there are other times when a well-meaning health care provider has given incorrect information to the patient and disappointment results.
Although the list of spine related conditions and associated symptoms is vast, only a very small number of these problems can, or should be, treated surgically. When evaluating a patient for potential surgical indications we always start by looking for those few and serious “red flag” conditions that require emergent surgical care. Such conditions could include unstable spinal injuries, infections, tumors, or severe neurological impairments. Beyond this, most conditions can be worked up and treated in an outpatient setting.
Although exceptions exist, in general, the most common reason to offer surgery is to correct the neurological consequences of spinal nerve compression. If a spinal nerve is compressed or pinched, a patient may suffer neurological consequences in their arms or legs. Numbness, pain, and weakness in one or more extremities are the more common associated complaints. The pattern and distribution of the nerve symptoms must correlate with some type of positive imaging finding that relates back to the effected nerve. Correction of a spinal deformity, such as scoliosis or spondylolisthesis, would be other less common reasons for spinal surgery.
Notably absent from the list of surgically correctable spine conditions are treatment of isolated neck pain and back pain. Although these represent the most common reasons for patients to seek spinal care, neck and back pain alone are almost never successfully managed by spine surgery. False expectations that such “axial” pain can be treated with surgery often result in disappointment when patients hear the reality that it can’t.
When evaluating patients for potential surgery a surgeon must also be aware of other medical conditions that share or mimic symptoms of spinal disease. Arthritis of a hip or bursitis of a hip are often misdiagnosed as back pain. Shoulder bursitis or rotator cuff injuries are often confused with neck pain. Even carpal tunnel syndrome can cause neck pain! So, an accurate diagnosis is critical.
Finally, before offering any patient surgery we must be sure that all reasonable and necessary attempts at conservative care have been employed. Given enough time and attention, many painful spinal conditions will resolve with non-surgical measures only.
In conclusion, I sincerely hope that the above explanation allows you to better understand our thought process when evaluating patients as potential surgical candidates. Most of the criteria and guidelines are based on years of experience which have been compiled and studied to better help you enjoy the best possible results from your spinal care, whether it’s surgical or otherwise. These criteria are guidelines, not rules. The final decision is a shared one between the doctor and patient based on individual circumstances and trust.
Wishing you good health!
Dr. Warren Wulff
Syracuse Orthopedic Specialists