I was a trauma surgeon for many years and I loved everything about it.
Trauma surgery is unique in surgery because it is a specialty that is almost pure surgery: very little need for elaborate consent forms or persuading a patient that surgery is required, because minutes matter. We race to the OR and fix whatever problem that a car crash or gunshot wound may have created. In some sense, it’s simple: when you’re stopping the bleeding, you know you’re doing the right thing. There is also a singular moral clarity to trauma surgery: we had no interest in who would pay for an operation, and we took equal care of everyone, victim and the mugger alike; we just let financial services and the police sort out the details the next day. And there’s this: occasionally many years later a stranger would approach me and say simply, “I’m sure you don’t remember me, but you saved my son’s life. Thank you”.
Long story short: surgery. I’m a fan.
So, I was a little surprised at my reaction when a few days ago, we got an email from Ken. It went like this:
I am the guy who recently sent in a review. You might be interested to know that my original back surgery was scheduled for this coming Monday. I have now canceled it because your chair has totally removed my back pain. Hope it stays that way! Ken
I was delighted to hear that Ken was able to skip his OR date and do something more fun and less uncomfortable than have an orthopedic guy workout on his lumbar vertebrae for a few hours. Yes, I believe in the art of surgery, and I well know that it can immensely improve people’s lives. But I also know that the only operation that is certain not to have any complications is the operation that you don’t do. And whenever possible the non-surgical option is the place to start because it’s safer and cheaper. You can always do an operation later if less invasive alternatives don’t solve the problem.
Of course, every surgeon knows that not every problem has a surgical solution. If you operate on a problem that can’t be improved by surgery, well, a lot of time and effort are wasted and no one is happy. Because back pain is a particularly difficult symptom to accurately diagnose, it’s certain that a lot of back surgery is unnecessary, even counterproductive. Indeed, a recent review found that fully half of all second opinions regarding spine surgery disagree with the first opinion1, so it’s clear that spine surgery isn’t the science that we wish it was.
Just how much spine surgery is suspect is difficult to say, but at least 17% of back surgeries are objectively felt to be unnecessary.2 And the problem seems to be getting worse, with rates of back surgery, and especially complex back surgery, climbing dramatically over the last several years.3 Problematically, editorials in medical journals note that the profit motive in back surgery is at least part of the problem.4
All this is made more fraught because back surgery is irreversible. That is, once a spine is rejiggered in the OR there’s no going back to the spine that was. So, one wants to be pretty confident of the diagnosis before diving into a life-changing operation. For a book-length discussion of the back pain industry, see Cathryn Jakobson Ramin’s excellent book.5
Will Ken stay cured? I don’t know. Indeed, we can’t know, because back pain can be a wily opponent, sometimes waxing and waning inexplicably. In ten years, we’ll know pretty much for sure; right now, it’s really too soon to say.
But I think Ken might well be out of the woods. And I’m rooting for him, just as I root for all my “patients”.
POST SCRIPT: A few days after I wrote this blog, we got an email from Kate, who seems to think her chair has at least postponed a hip replacement operation:
“I have arthritis in my left hip and seem to have pain when walking most of the time. This chair is a miracle! While I still expect to have hip replacement surgery eventually, this chair has made my getting up off the chair and walking easy by simply changing the way I sit.”
Kate’s problem is arthritis, not back pain, so, a completely different problem than Ken’s back pain. But we know that movement is helpful for easing arthritis, so it’s not implausible that active sitting will help Kate cheat her surgeon out of an operation. I’m rooting for Kate, too.
1Second opinion in spine surgery: A scoping review
2“Unnecessary” spinal surgery: A prospective 1-year study of one surgeon’s experience
3Surgery May Not Be The Answer To An Aching Back
4The Increasing Morbidity of Elective Spinal Stenosis Surgery
5Cathryn Jakobson Ramin; Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery, 2017