Dr. Allan Horowitz, published newspaper article, The Liberal, Copyright May 1, 1991
For the past few weeks I’ve been outlining factors to be considered in the decision-making process one goes through when considering back surgery.
A reader wrote to me that he was very confused because of the many different opinions he was receiving regarding his back pain, and whether or not he should have surgery to correct the problem.
This week, as promised, I will discuss some of the factors surgeons consider when trying to determine the outcome of lower back disc surgery. In other words, they use these factors to decide if the patient will likely be better, worse or no different after the disc surgery.
Incapacitation: is the patient incapacitated by his or her pain? If the pain is not really bad enough to alter the normal living of the patient, they will usually not be satisfied by the outcome of any surgery.
Leg Pain: usually disc surgery will eliminate most, if not all of the leg pain, or sciatica. It usually relieves some, most or all of the lower back pain. If the leg pain, which often accompanies back pain, is not present to any great degree, thepatient may not be pleased that their ‘minor’ leg pain is gone; but their ‘severe’ lower back pain is not much better.
Position: if changes in body position do not affect the degree of back or leg pain, then surgery may not help. If the pain is caused by pressure from a bulging disc, then changing body position should change the pain (worse when sitting, relieved by reclining, etc.). If positional changes don’t really affect the pain, then removal of the disc might not help either.
One Nerve Root: when removing part of a disc to relieve pressure from a nerve, it is much preferred to have one single nerve involved. If neurological examination shows that several levels of the spine are involved, the results of surgery are not likely to be good.
Findings Correlate: If the C-T scan, myelogram, X-rays and all other test results all point to one, single source of the patient’s pain, then the surgery directed to that source is likely to be successful. If there is any confusion regarding the soured of the pain, surgery shouldn’t be done.
Straight-Leg Raising and Crossed Straight-Leg Raising:If the straight leg raise test is highly positive (any patient who has had a disc problem knows very well what this test is), then surgery should be considered. If the crossed straight leg raise test is positive, it should be considered even more.
Patient’s Thoughts: I touched on this factor last week when l mentioned that the doctor has to “feel the patient out”. If a patient expects great, immediate results without changing certain lifestyle factors, the surgeon might be advised to wait until the patient changes some attitudes. A patient who has a realistic attitude, listens to his or her doctors, and follows advice will do better after surgery. A positive mental attitude always helps.
The above factors are what a surgeon will consider when trying to decide to operate on a patient with a certain type of lower back condition. These (factors apply to ‘disc surgery’ and I do not mean to imply that these factors should be considered for all types of back surgery.
Some back surgery should be done even if these factors are not present. Just because there is no leg pain, or the straight leg raise test is negative, doesn’t mean that back surgery shouldn’t be done. It depends on what is causing your pain.
There are many, many other conditions which require surgery, and I don’t want this column to be used as a defence against this type of surgery.
If your doctor finds a tumor in your back, or if you fall and fracture your spine, and if your surgeon tells you that you need immediate surgery, I don’t want you to tell him or her that you don’t have any leg pain and therefore Dr. Horowitz says you don’t need surgery.
Next week I’ll outline some of the ‘negative’ predictive factors for lumbar disc surgery. In other words, if you have many of these factors present, it might be good to avoid surgery.