By Wesley A. Rowe and Vernon Rowe, M.D.
This article takes for granted that you are already aware of the slippery slope of spinal surgery for back pain and neck pain. Put concisely, one bad thing leads to another. Surgery is never the “final answer” for back and neck pain. Just as injury begets weakness which begets more injury, one spine surgery frequently leads to more spine surgeries. And spine surgery is one of the highest profit centers for our hospital-centered healthcare, in the medical-industrial-congressional complex.
It’s a complex topic, and decisions must be individualized for each patient. But at RNI we learned from seeing thousands of patients with back and neck pain over the years, that surgery often leaves behind weak tissues that lead to more problems for patients. Click to read a fuller discussion of the risks of back surgery. So you need to educate yourself about the problems with rushing into surgery, when more conservative and effective therapies are available.
Update: Dr. Rowe relates his personal experience of a complete workup of his back, performed the way it should always be done. The article continues below, discussing 7 reasons why a thorough independent evaluation is the first step in finding help for back pain.
Generally it is best to see a neurologist for a complete workup of your back pain and the neurologist recommends a surgical opinion, before seeking a neurosugeon. In my case, as a neurologist with years of experience with my back, I wanted a neurosurgical opinion. This is after fifteen years of excellent physical therapy by Optimum Physical Therapy in Kansas City, who helped me maintain spine health after wide laminectomy. What follows here is my personal experience with medicine the way it should always be practiced.
I was lucky enough to see a world-class team with many years of experience treating back pain disorders. I can only describe my experience yesterday at the University of Missouri, Columbia, to give a testimonial to such a world class center.
“I arrived at clinic early, and saw Dr. Paul Santiago at 8:15 AM. He listened to my story of worsening back and leg pain and nearly fifteen good years after a wide lumbar laminectomy and continuing PT, and did a complete neurologic exam. (Being a neurologist myself, and very cautious about back surgery, I was having to go to office those fifteen years ago and lie on the floor between patients before I sought help. How I got there was crazy stunts on horses and years of low back abuse, but that’s another story.)
Dr. Santiago and I realized together that I had a (previously unsuspected) pars fracture, and other changes, but that my primary problem was in the mid-back, at the L3 level, and could cause all my symptoms, including those that had been mistaken for appendicitis.
Stunned, I said ,” But what about all this other stuff…” He smiled and said, “Look. You wanted me to improve your quality of life, right?” First words out of my mouth. “If we do anything, it will be at the L3-4 level. Okay?” So I smiled back. Those magic words, “quality of life,” so often talked about but seldom practiced, given the systematized and siloed healthcare of today.
I had already had an MRI and CT-without contrast of my back before my visit, and those had been reviewed. Next at 10:00 came a special set of dynamic X-Rays of my entire spine, to make sure all its aspects move together, and correctly with my eye movements, so important in spinal tone and movement.
At 11:00 AM came my EMG, done also in a world-class way, by Dr. Mark Drymalski. Being boarded in this crucial test, and having done about 25 K of them over the course of my career, I know great when I see it. And this one was great. The previously suspected lower levels were not a major problem, and the nerves to my legs and feet were excellent in a general way.
At 1:00 PM came the selective nerve root injection at the L3 level on both sides, by Dr. Ebby Varghese. This was done as much a diagnostic test as a “cut-to-the-chase” therapeutic intervention. Sure enough, injection at the L3 nerve root, especially on the right side, reproduced my symptoms that mimicked appendicitis and groin pain. For the first time in months, I was pain free with the local anesthetic. I knew it would take the steroids a few days to kick in.
Because of seamless communication between all members of the whole team, I avoided the standard ESI (epidural steroid injection) that would almost certainly have punctured my thecal sac and resulted in continuing spinal tap headache and other surgery. (For a description of this complication, see elsewhere on this site.)
Soo…because of the excellence of the physicians and nurses and the teamwork at MU, his team approach, I had a diagnosis and initial treatment in this truly “complex spine”, that had served me well for all my years., before 2:00 PM. Wow! I wasn’t told to “come back when your bladder doesn’t work or your legs give out.” I wasn’t pitched an operation, at the wrong level, and because of my missed pars fracture would almost certainly have led to other operations in a “failed back” routine. I didn’t have steroids blindly injected into my back, which almost certainly would have given me lasting headaches. And I had an expert EMG to provide information on nerves in general, and on other spinal nerve roots in particular. (See elsewhere on this site.)
What I experienced was expert care in the hands of a world class team at the University of Missouri, Columbia. I know world class when I see it, from training at Duke, Johns Hopkins, the NIH, Seattle, and having rotated through a couple of the Boston hospitals, and from visits to others all over the US and the world.
There are gems made possible by the US healthcare system, not present anywhere else in the world. And the care of Dr. Paul Santiago and the team at MU that I just experienced is one of them. Those folks have a calling and not just a job.
MU can also claim Dr. Richard Barohn, a world thought leader and pioneer in Neuromuscular Neurology; Dr. Adnan Qureshi, a world-class endovascular interventional Neurologist; and Dr. Michael Chicoine, an expert in skull base surgery and neuro-oncology. And there are many others I haven’t mentioned.
The only note of caution, and nobody’s perfect: these folks appear to all be enthusiastic Mizzou basketball fans. Having been a Duke and Kansas fan for the last few decades, I know I will be conflicted at times, but maybe it’s time to broaden my approach to the brackets this March. Verbum sat sapienti.”
Evaluation of Spinal Disorders in Patients with Hypermobility Syndromes
A comprehensive spine evaluation in a multispecialty spine center is particularly important in patients who are hypermobile, where joint pain, back pain, and neck pain, as well as other symptoms such as headache and sleep disorders, may be caused by ligaments that are lax because of a connective tissue disorder. In fact, many physicians who treat patients with back and neck pain do not know how important it is to obtain spine X-Rays in the lying, standing, and bending positions to determine whether the spine shifts with weight bearing. This simple series of X-Rays, in addition the MRI testing, can radically change the way spine pain is treated.
Why diagnosis by an independent neurologist is crucial in back pain and neck pain
Neurologists and other physicians are increasingly employed by hospitals and hospital systems. These hospitals and systems benefit immensely from spine surgery. Thus, an independent Neurologist may be inclined to seek out non-surgical options for you before any referral to an in-house spine surgeon.
We have tried to capture the value of this approach by sharing a woman’s story (and video) of going from wheelchair to pain-free walking, and we hope that you will check it out. It’s quite a story, and hopefully you will find inspiration in it.
Many Surgeons have an inherent “lean” toward surgery. They do order diagnostic tests like MRIs and x-rays, just like a Neurologist or family doctor can. But surgeons can’t help seeing most patients with their most powerful tool in mind. Oftentimes they ask the question “Which surgery can help this patient,” rather than “does this patient really need surgery” to improve their quality of life. Patients don’t want surgery if they can possibly avoid it. Thus, even the best surgeons may see you through a different lens than you see it yourself.
Any neurologist is highly specialized in diagnosing back pain and neck pain, and in assessing risks and treatment options. Every back pain and neck pain patient is unique, with different degrees of problems associated with a bone or disc abnormality. A neurologist is trained to discover the causes of symptoms. Some are trained in Neuroimaging, and can go over your imaging studies, like X-Rays and MRI’s with you. In addition, they look at your “electrical system” by using EMG testing to assess the injury to nerves ,and whether that injury is reversible in the short and long term.
However, if a neurologist sees a patient who is first seen by a spine surgeon in that same hospital system, then that neurologist may be prejudiced in his or her assessment. The primary duty of any clinician should be to the patient, to provide the best care possible, and not to prevent “leakage” of patients out of any hospital system. So patients should always get a second opinion from an independent Neurologist, or at least one who is not an employee of the same system. In most non-emergency cases, a conservative approach is both possible and optimal.
A Neurologist can give you the most informed and trustworthy referral to a surgeon. An independent neurologist who has seen thousands of similar patients can find the best surgeon for your case. Unfortunately, some patients can’t be helped by even the best physical therapy. Disc herniation can be too extreme, bone can build up around nerves to the point where they no longer fit through, or the spine can become unstable on standing for many reasons. All Neurologists will know fine surgeons they can rely on if surgery is necessary, no matter which hospital system that surgeon is in, and they can give patients multiple options should the patient need surgery.
Neurologists make a long-term connection with patients. Surgeons don’t generally care for patients with back pain and neck pain over the long term. The last time you see a surgeon is likely at a post-op follow-up visit a month or two after surgery, long before you are fully recovered. There are many “cracks” to fall through later on, the most important being a return to the same posture and muscle conditioning that led to the injury in the first place.
A good Neurologist will coordinate all aspects of your treatment, from diagnosis to recovery and prevention of re-injury. And you should try to find such a Neurologist, one who cares about you, and makes decisions as if you were one of his or her family. For example, not all imaging facilities are alike, and it is important that your neurologist send you to one that does good images, and that they show you and explain what is seen there. Another important aspect of imaging is cost: MRI’s done at hospital owned facilities generally cost up to three times what is charged at independent imaging facilities. But you have the option of obtaining your imaging at an independent imaging facility, where your co pay and your insurance costs will be lower, and yet the quality just as high as at a hospital-owned facility.
Highly specialized physical therapists are critical for your care-to follow your case from your first visit through resolution of your symptoms. Appropriate physical therapy can get the majority of back pain patients better without surgery, by re-training the muscles of the hip and abdomen to support the back the way they were intended. What these physical therapists accomplish can seem like a miracle to the patients they help.
Hospital-employed physical therapists usually only treat post-surgical patients. So you should find a therapist you can interview and determine that they understand that you want to avoid surgery. In Kansas City, the team at Optimum Physical Therapy in the Northland do the best job, in our experience. Others are available in LA, but you must realize that therapy is critical to resolution of your symptoms, and if you are not improving with your current therapist, then you need to move on.
A good neurologist will support you in the long term. Back injuries are a long-term problem, and to fix them a great deal of commitment is required of the patient. That commitment can keep you healthy and out of surgery, but you can’t do it on your own. A team of nurses, physicians, and physical therapists need to support you all along the way.
Go to DoctorRowe.com for more videos on Back and Neck Pain
Dr. Vernon Rowe has a web-based informational website that provides in-depth information about each of the neurological conditions that we specialize in, including informational videos like this one, with transcripts, that are unlike anything else on the web–they are NOT SPONSORED by any pharmaceutical company or other commercial entity. Go to DOCTORROWE.COM. The information provided will help you navigate your care wherever you go, with knowledge about the questions you should ask your doctor, and the tests that may be recommended, as well as some tips on how to obtain cost effective care, wherever you live.
by Vernon Rowe, M.D. –
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