Working With Patients on a Noninvasive Alternative to Surgery

Yet another good quality study has shown that there is no benefit to surgery for degenerative disc and joint disease (DJD), especially of the cervical and lumbar spines. (Fairbank J. Total disc replacement for chronic low back pain. BMJ 2011 May 19; 342:d2745). Yet every day I come across patients in chronic pain who have undergone invasive management because their doctor or surgeon told them that soon they would be paralyzed if they didn't choose surgery. This needs to change. There is no evidence to indicate that surgery is better than noninvasive care for patients with DJD of the spine. (This discussion applies to DJD and spondyloarthritis of the vertebral spine, not to spinal stenosis or cauda equine syndromes, situations in which surgery is standard of care).

Modern mainstream noninvasive therapeutics is so bankrupt that most allopathic practitioners recommend surgery for the problem of chronic back pain attributed to disc disease. However, close to 100 percent of patients with disc disease have systemic causes of their back pain and disc problems. Systemic causes include smoking (leading to bone resorption, atherosclerosis, and inflammation), inadequate micronutrient intake and cardiometabolic disease (obesity), and many are simply the type of patients who will be in chronic pain no matter what happens to them - those people with ”fibromyalgia,” ”endometriosis,” and “chronic fatigue and pain syndromes.“ These people have brains that process pain signals aberrantly. Interestingly, sham surgeries have been shown to have some benefit, but that doesn't mean surgery should actually be recommended. The clinical utility of placebos has been known for millennia, but in this case it just should not be done, because invariably, patients end up in more pain after than before surgery.

The same applies to surgery for chronic abdominal pain and endometriosis. There is no evidence to indicate that the amount of endometriotic tissue located in the peritoneal cavity correlates with pain; some patients have plentiful ectopic endometrial tissue in their bodies, and are in no pain at all, while some patients have a small amount of endometriotic tissue found after a laparotomy performed to evaluate for structural causes of pain. Of course, surgery is indicated at other times, such as when the ectopic endometrial tissue forms a space-occupying mass in the pelvis, pushing on other structures.

But we must never forget that pain perception especially in chronic pain syndromes, is a brain phenomenon. Therefore you cannot fix it by going after anatomical body parts outside of the brain. The American Pain Society recommends delving into psychiatric, behavioral, and systemic explanations of and solutions for chronic pain.

Most patients I meet, both in the hospital and in the community, tell me that their physicians push them to have surgery on their cervical or lumbar spines because such procedures supposedly prevent neurologic deterioration. In response I tell them and I repeat to you, first, don’t consent to surgery right now. Second, you have time to think about it and pursue a conservative approach. Chronic disc disease of the back is slow and progressive, not an acute emergency such as metastatic spinal lesions or epidural abscesses. The patient usually has time for a comprehensive treatment plan.

A comprehensive treatment plan is a systematic, thorough, painstaking therapeutic program that takes time for implementation and results. What is essential is the following: recognition of what is going on in the patient, such as past radiographic findings. It is important to realize that chronic pain patients typically have complex emotional lives, often have a history of physical, domestic, or sexual abuse, a history of depression, anxiety, and/or substance abuse, and are often deeply disappointed people. Somatization is major pathophysiologic mechanism in chronic pain patients. After recognition of this, rapport establishment is necessary. Usually one is acknowledged as the first doctor ever to acknowledge the underlying story which is the cause of their pain, and therefore of their truth. The patient will often relax and smile upon realization that they have an ally in you. Furthermore, that acknowledgement will be reified by medically treating pain with opiate analgesics. Why? Because you need an acute fix to buy time for the chronic fix that requires time. It is important to dose low, and avoid titrating up too much. The American Pain Society suggests that more than 200mg of morphine equivalents per day can lead to narcotic hyperalgesia. I interpret this as do not ever titrate up to that much for any reason whatsoever.

The essential components of comprehensive therapeutics at this point forward include focusing on creating a healthy lifestyle. This means methods practiced daily for increasing exercise capacity, daily stretching, joint rotation, consumption of beneficial supplements, increasing levels of Vitamin D, smoking cessation, an anti-inflammatory diet consumed daily, and active efforts to address psychospiritual and emotional issues. I will delve into specific components of such a program in the future.

For more on Dushyant Viswanathan and our other Practice Notes bloggers, click here.