500,000 Americans have spinal fusions every year and the most common reason is for “chronic pain.”
But before you decide to have surgery consider these facts:
Right now there are no ‘good’ ways to predict who will get better with these major surgeries.
(A flip of the coin is about as good as it gets right now).
Unfortunately, many people don’t get better after surgery.
Some even get worse.
And for those who do state improvement right after surgery…few studies follow-up with them years or even months later to see if it lasts.
Why is this?
To answer these and other questions we’re lucky to have Dr. David Hanscom on Straight Shot Health Talk.
Dr. Hanscom is an orthopedic spine surgeon who has been practicing for 30 years.
He’s the surgeon other spine surgeons call for help because he’s the guy who treats the most complex and difficult cases.
And in this episode we talk about why the most common reason for spinal surgery is, for many cases, the worst reason to have it done.
FULL TRANSCRIPT OF EPISODE BELOW:
Hello, listener, and welcome to Straight Shot Health Talk. This is the podcast that provides honest and straightforward information about health, wellness and how to survive our crazy healthcare system. This is for people who want to focus on getting well instead of just treating symptoms. Sounds like you? Then let’s get started.
Dr. Kevin Cuccaro: All right. Welcome back everybody to another episode of Straight Shot Health Talk. This is your host, Dr. Kevin, and my guest today is a very special guest. This is Dr. David Hanscom.
Dr. Hanscom is an orthopedic spine surgeon performing predominantly very complex reconstructive spine operations at Swedish Hospital in Seattle. He’s a board certified orthopedic surgeon. He has expertise in both adult and kids’ spinal deformities such as scoliosis and kyphosis, which is a humping of the spine. And he has devoted his practice in many ways to doing surgery on patients who have had multiple prior spine surgeries.
He also is an interesting surgeon because he actively doesn’t want to operate on people. He is looking for people who have spinal deformities. He does no longer operate on patients for back pain, but I’m going to let him talk to us about that itself. This is going to be a very important interview and I would advise you to maybe sit down, take a little time here, and maybe take some notes throughout it.
Dr. Hanscom, thank you so much for joining us on Straight Shot Health Talk.
Dr. David Hanscom: Hi, Kevin. I appreciate being on the show and, yeah, I’m happy to tell the story, give you a little bit of perspective.
I’ve been a spine surgeon in Seattle since 1986 and I trained in Minneapolis, Minnesota, which was a major spine deformity fellowship at the time, still a pretty prominent fellowship. And I came out of there on fire. I’d been on one of these — I’m one of the surgeons whose been on both sides of this fence, and for about seven or eight years I did many, many back fusions for back pain, because that’s what I thought I was supposed to do. I felt good about it. I was zealous about it. And I kept getting frustrated because people just weren’t doing very well. And I would use a test called a discogram. We would try bracing. We would try all these things to try to figure out who would do well and who would not do well with spine surgery.
Then in 1993 Dr. Gary Franklin in Washington published a paper showing that the return-to-work rate in the state of Washington after a spine fusion for back pain was 15 percent, 1-5 percent. In a two-year followup, the return-to-work rate was 22 percent. And then I looked at my own results. I looked at that data and I just stopped, because I realized that the fusions for back pain were not doing well.
Then about the same time a lot of my patients that had had fusions started breaking down above and below their fusions and a lot of patients became referred to me for breakdown above and below their fusions. And those are real problems. Those don’t do well without surgery.
So the combination of patients not doing well with the back fusion for back pain and perhaps I was actually causing problems by doing a fusion, I just stopped doing the fusions back in 1993 for back pain.
Dr. Kevin Cuccaro: Okay. Can you describe a little bit about what a lumbar fusion is and what the most common indication is? It’s just important for the listener to, you know everybody hears back surgery, but there’s different types and it’s really important to kind of differentiate those.
Dr. David Hanscom: So the basic theory when I was doing the fusion for back pain was that the disc itself, the space between the vertebrae was the source of the pain. If you destroyed the disc by welding it together — so what a fusion does it takes two vertebrae and turns it into a solid piece of bone. We use hardware, like screws and plates and rods to hold things together temporarily until the fusion heals. If the fusion doesn’t heal, the hardware will loosen or break. So the fusion depends on creating a solid bridge of bone between two vertebrae. So the theory is that if you get rid of the motion, get rid of the disc movement, you will get rid of the pain.
What’s really interesting is that we’ve known for decades that we do not know often what causes back pain. It’s actually been well-documented in the literature that disc degeneration is actually not a cause of back pain. In other words, if you take 100 people off the street with normal spines, a high percent of those will have back pain like everybody else. We take people with degenerated disc, arthritis, bone spurs, those people do no have back pain any more than the general population. In fact, many of them have no back pain at tall.
They’ve done even long-term follow-up studies to find out if you have disc degeneration the chance of developing back pain is no higher than a person without disc degeneration. So it’s interesting that we actually do know that disc degeneration doesn’t cause back pain, yet at the same time, the medical and surgical community seems to ignore that data and is actually performing hundreds of thousands of fusions on back pain.
Dr. Kevin Cuccaro: Yes. You know, I’m just sitting here nodding, which nobody can see. I just think it’s absolutely astounding, because if you look at the data, I mean, there’s just paper after paper after paper that says disc degeneration is normal.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: And what I also see is the danger is someone gets back pain and they go in and they get an MRI and we know that early MRIs have an increased risk of postsurgery and chronic pain, but then the doctor looks at it and says, well, your pain is coming from this degenerative disc. And how —
Dr. David Hanscom: Right. Now, there’s also a paper out, done last summer, which shows that doctors right now are simply ignoring clinical guidelines when it comes to chronic pain. There’s also data showing that people in the alternative medicine world are more effective dealing with back pain than traditional medicine.
So this story gets more interesting, is that there’s a paper in 2006 that showed that if you take a very carefully selected group of patients who did not have anxiety or depression and you did a one or two-level fusion based on what’s called a discogram — that’s where you inject dye into the disc to see if it’s painful — that the success rate was only 27 percent period. And most people when they sign up for back surgery are thinking in terms of 80 to 90 percent success rate; otherwise, why would you just have such a definitive operation if the success rate was 25 percent? And, as we all know, the placebo effect is somewhere from 25 to 50 percent, so this doesn’t even really reach placebo.
On top of that, what I see is that once you’ve done a fusion, you’ve actually surgically assaulted the spine and the spine is stiff. It has scar tissue. The spine will often breakdown above and below the fusion and I’ve had people, we had one lady we operated on last week, that started out with a normal spine about seven years ago. She has had 10 operations. She is now fused from her neck to her pelvis. And she started breaking down, breaking down and we just spent 15 hours last week trying to get her spine straight again. She lost 15 units of blood. Society has probably spent over $3 million on her care. And she’s a train wreck. She’s not going to do well no matter what we do.
So, that’s just one — I probably see one in three patients every day in my office that have essentially normal spines for their age, that have had either major fusions done or recommended for back pain. And there’s no pathology there to operate on.
Dr. Kevin Cuccaro: I don’t want add a lead-in question here, but why do you think that is? Why do you think these fusions are being done so frequently?
Dr. David Hanscom: Well, I mean, the people will give the simplistic answer because it’s about money and production and part of it’s true, but there’s a bunch of other reasons. Patients themselves actually demand the surgery. When patients come to me with their back pain and I say, look the success rate is 25 percent. There’s really nothing to operate on. It’s actually a very unpleasant experience because the patient just explodes. They start ranting and raving about their pain. How nobody’s listening to them. How I’m their last hope. And I’m going that’s fine, I understand you. We have solutions for your back pain, but it’s not surgery.
So it’s actually fairly unpleasant to tell a patient who is demanding surgery not — that you can’t do surgery, number one. Second of all, doctors do get paid well for doing surgery. We don’t get paid well for not doing surgery. So the patient’s demanding surgery. The hospital system is demanding production, which means more procedures, but also the patient’s themselves would rather have something done to them than to do something for themselves, like do solid rehab, etc.
So it’s a combination of forces I think that causes the rate of spine surgery to go up. The other two things are that doctors themselves are simply not taught anything about chronic pain in medical school, residencies, or fellowships at all, so we’re just doing what we’re trained to do. So we don’t really have an awareness of the other possibilities.
Dr. Kevin Cuccaro: No. I completely agree. You know, I think the other problem is we’re taught in medical school that we’re supposed to be having the answers and I could just imagine for a surgeon when you’re supposed to be providing definitive care it’s even worse.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: Where we want to do something. We are trained to do something.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: In a lot of cases, for many, many, many diseases, not just back pain.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: There really isn’t a whole lot we can do and it’s what we shouldn’t be doing.
Dr. David Hanscom: Right. The part to me that’s become extremely interesting in the last month or two is that they’ve done these, what’s called a functional MRI scan research studies, where they inject a glucose into the vein that’s radioactive where it’s some type of magnetic dye. It goes to the different parts of the brain that shows where the brain is active versus where it’s not.
They took a group of volunteers who had had back pain for less than three months and when they scanned them, there’s a part of the brain that corresponds for the back pain center that lit up. Then they scanned patients who had chronic pain for more than 10 years and they found that the pain center had dropped down. The center that lit up was the emotional center. The problem is whether it was the emotional center or the pain center, it’s still hooked to the same pain generator, the amygdala, which caused a very unpleasant sensation.
So basically, the transmission’s the same, but you change the engines. So surgeries for acute pain to solve that particular problem, if you’re doing surgery and actually it’s the emotional part of the brain that’s turned on, it’s not going to work. So basically — then they did a — the part of this that’s very fascinating is that about half of the acute pain patients turned into chronic pain patients. They scanned the entire group every three months for a year. By 12 months, the pain center had switched completely over to the emotional center. So you can’t do surgery on emotional pain and expect it to work. You’re just shooting at the wrong target.
Dr. Kevin Cuccaro: Well, yeah, for that chronic pain is definitely a different entity from acute pain. I did a couple talks on this for the podcast, but I’m just going to remind people.
Pain by definition has two components to it. There’s a sensory and emotional experience and what I tried to explain to patients is you always will have that emotional — that central driver, which is that brain how it processes that signal that’s coming from the body and in chronic pain that’s often the primary driver.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: And if we do anything to eliminate that peripheral nerve fiber, that no susceptive signal, we haven’t done anything to affect that central role. And for me when I was doing injections and things, it wasn’t uncommon that maybe their back would feel better with an injection, but they would start complaining about shoulder pain or something else and it’s because you have all these nerve transmissions coming from your body, going to that same sort of central processing unit that is firing aberrantly.
Dr. David Hanscom: Right. Well, it even gets more interesting because also we know that degenerated discs do not cause back pain. We also know that anxiety and depression have been negative predictors; I’m sorry, predictors of negative outcomes for many, many decades. So we know in the presence of — there’s over 1,000 research papers documenting that if you’re anxious or depressed or both that the chance of a successful surgical outcome is dramatically compromised. In fact, there’s more correlation of a successful outcome with a state of mind than there is actually with the anatomy.
On top of that, there’s several research papers showing for hip and knee arthritis that the severity of the arthritis has nothing to do with the pain. In other words, people with bone-on-bone arthritis often have minimal pain. People with minimal arthritis often have severe pain. What they found out that actually correlated with the degree of stress.
So it both sounds like this interpretation of the pain signal is very subjective based on the given mood, given day, given stress and my patient that are good at this have a clear connection between stress and the pain. So pain’s a stressor; there’s other stressors. It’s not psychological; it’s just an intertwining of the pathways.
So what happens, we now take all our patients for any surgery, we put them through a six to 12-week process, sometimes longer. We get them sleeping, which calms down the nervous system. We start some simple writing exercises. And the bottom line is we decrease their anxiety by at least 50 percent. What we have found out, we have over 30 patients now that we’re writing our research paper on that as we’ve calmed down the nervous system, it seems to raise the pain threshold, even with pretty major structural problem, which do respond well to surgery, their pain goes away. They’ve never gone to surgery.
Dr. Kevin Cuccaro: Yeah. That’s fantastic. That’ fantastic.
Dr. David Hanscom: Yeah, and that I did not expect. That came out of the blue about two years ago. So we’ve got 33 patients now we’re writing this research paper on and it’s unbelievable.
Dr. Kevin Cuccaro: Yeah, it is. It’s fascinating because people — this is the other frustrating thing I have about pain, is that people do try to distinguish between a real pain and an unreal pain and oftentimes they’ll say, well it’s an emotional pain is unreal pain and all pain is pain. And all pain is unpleasant and destructive. It’s really trying to address that those factors that propagate pain. And anxiety, depression, anger are huge drivers in the pain experience, so.
Dr. David Hanscom: Well, we also know the mental pain and physical pain are processed in basically the same part of the brain.
So we put on a seminar back in New York at the Omega Institute. We basically treat mental pain and physical pain as exactly the same entity. And indeed, as anxiety drops, their pain drops. As their pain drops, their anxiety drops. So they’re just interconnected, intertwined pathways. Remember when a pain signal comes from your knee or your hip or your back, then it has to be interpreted by your brain as positive, neutral, or negative.
Same thing with all your other emotions, has to be interpreted as positive or negative by the nervous system. So that processing center exists in about the same part of the brain, so there’s really actually not much point in even trying to differentiate those two.
Dr. Kevin Cuccaro: Yeah, no. And I wish we would quit using those terms as physicians.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: It’s a long battle though. As I do some talking to physicians here and it’s not uncommon that they’ll say, well is this real pain or unreal pain or this is emotional pain —
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: — versus physical pain. It’s like, it’s all pain.
Dr. David Hanscom: Well, it gets even more interesting in that I have patients now that are 10/10 on their anxiety, depression, and irritability questionnaire. And I say, look, we’re not doing surgery until your anxiety is calmed down. I say, by the way, what if I did your surgery and got rid of your leg pain, would your anxiety stay exactly the same as this now? As you get older anxiety always gets worse. What would that be like? And they go, that would be terrible. And they instantly grab the leg and go, well, by doing surgery isn’t that going to calm down my anxiety? And I go, no. That’s a different problem.
So then I ask, well what if we calm down your anxiety and you had the pain left in your leg that you’re living with right now, what would that be like? And they go, well I wouldn’t like that, but I actually could deal with it. I mean the bottom line is that raw anxiety is almost intolerable. I went through this myself for about 15 years and it’s brutal. I mean raw anxiety is absolutely intolerable and so it gets mixed in with the pain system and it’s very hard to separate it out.
But what I finally realized that I’m asking the wrong question over the years, that what I’m really asking is that am I operating on your pain or your anxiety? And the bottom line is people really, really want to get rid of their anxiety.
But the final point I want to really make here, which blew me away, I think I sent you these papers, is that there’s actually dozens of research papers documenting that with simple, uncomplicated surgeries, like hernias, gallbladders, chest surgery, breast biopsies, et cetera, that there’s a 10 to 40 percent of actually inducing chronic pain with a simple procedure. And the risk factor is being anxious or depressed before the surgery, which is a treatable problem.
So if I told that my surgical complication rate was 10 to 40 percent, the odds are you are not going to send me much surgery, right?
Dr. Kevin Cuccaro: Yep.
Dr. David Hanscom: But on top of that chronic — but see my complications heal, whether it’s an infection or dural tear, those complications heal. Chronic pain doesn’t get better, unless you treat it correctly. So a 10 to 40 percent chance of actually causing chronic pain by surgery is huge. So surgery’s not only not the definitive answer, it’s actually quite risky.
Dr. Kevin Cuccaro: No, absolutely. Yeah, it just reminded me of something I was reading the other day about pain and I was wondering why it is so resistant in so many ways, but it’s basically a survival mechanism. There’s like two, I think it was two processes that we will never acclimatize to and one of them was loud noises. And I guess when we were running around through the plains or whatever 200,000 years ago, we needed to know loud noises so that we could hear the saber tooth tiger coming, but the other one is chronic pain. And both of those the brain does not adapt to.
Dr. David Hanscom: That’s right.
Dr. Kevin Cuccaro: And it’s just very interesting to me.
Dr. David Hanscom: No, I agree.
Dr. Kevin Cuccaro: Now, you did touch on something there and I would like you to, if you don’t mind getting into it a little bit more, because a lot of times patients or people they don’t understand or they may think that a doctor does not know where they’re coming from.
And particularly with chronic pain, a lot of chronic pain patients feel like they’re all alone in their pain; that no one else is experiencing things similar and then certainly not the doctor in front of them has experienced what they are experiencing and cannot empathize or really understand what it is that they’re going through. But that’s different with you. Would you mind talking about that a little bit?
Dr. David Hanscom: Well, I would not choose to do this again if I had a choice about this, but one of the huge advantages I have dealing with my patients in chronic pain is that I had chronic pain for 15 years and I would say seven of those years were almost intolerable. In fact, they were intolerable and I cannot believe I made it through.
So I actually have 18 medical colleagues dead from suicide and I was almost number 19, because I had no hope; nowhere to go, no way out. I was absolutely miserable beyond description. So I had, what I only found out a few years ago what I was actually suffering from was called mind-body syndrome and I also did not realize that chronic pain is one of the core symptoms of mind-body syndrome, as well as anxiety.
So not only did I have extreme anxiety, I developed what’s called an obsessive-compulsive disorder, which is the ultimate anxiety disorder and that’s multiple repeated, unpleasant, intrusive thoughts and, as you know, when we try not to think about something, we think about it more. And there’s nothing I could do. I tried medication, meditation, all sorts of stuff.
So one thing people don’t understand when my patients tell me that I don’t understand how they feel, that there’s no human being that suffered more than I did. In other words, somebody might have suffered as much as I did; nobody suffered more. I was in chronic pain for 15 years. Some of those were absolutely intolerable. And that’s a long, long time to be in that degree of chronic pain. So yeah, I got through it.
So the book I wrote actually came out of that experience, it was “My Journey out of Chronic Pain.” And I learned none of it medical school or residency or fellowship. I didn’t even learn it in practice and it was finally after looking backwards, looking at my own experience and piecing things together did we get a consistent pathway that people have been really successful with.
Yeah, I’ve actually seen hundreds of patients now go absolutely pain-free. It’s not about managing the pain, people really do go to pain-free.
Dr. Kevin Cuccaro: Yeah, I think that is one of the most amazing portions about that too is it really is people go pain-free.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: And we don’t say that for anything else. We say, oh, we’re going to reduce your pain by 50 percent with this or maybe it’s going to last six months.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: It’s really the difference about treating a symptom versus treating a source.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: And if you address that source, you can actually cure it. And I think that’s just absolutely amazing.
Dr. David Hanscom: Right. Well, it’s also fascinating there’s over 30 symptoms of what’s called the mind-body syndrome. I had 16 of those at the same time. And what happens, your body is full of adrenaline because of the stress. Every organ system responds in a different way. So I had migraine headaches. I had burning in my feet. I had back pain, neck pain, tension headaches, insomnia. I had ringing in my ears. And all those things are gone. I mean it’s unbelievable.
So as your body — as my adrenaline levels dropped, all these other organ systems calmed down also. It has been a remarkable journey.
Dr. Kevin Cuccaro: And without pills and without surgery?
Dr. David Hanscom: Yep. The pills didn’t work buddy. I tried medications, counseling, all sorts of stuff and nothing broke it. So I just got very, very lucky coming out of the hole. So that’s where the book evolved from was — I got lucky and then I started figuring out working backwards what happened. But I mean 15 years is a long time to be in chronic pain.
Dr. Kevin Cuccaro: Oh, absolutely. Absolutely. And your symptoms, as I said, were very, very interesting and I do — I just think it’s important that people understand that there are physicians out there in chronic pain. That people have often gone through these experiences. And when you’re telling someone I don’t — I’m not going to operate on you and it’s because I don’t believe it’s going to help you, it’s because you honestly are not trying to deny them from care or — God, I’m trying to think of other weird things I’ve heard from people. It’s Obamacare or if I had insurance or good insurance you’d do this.
Dr. David Hanscom: Right.
Dr. Kevin Cuccaro: It’s, you’re actually looking out for these people. You don’t want to hurt them more.
Dr. David Hanscom: Well, again, go back to that one study. I mean dozens of studies and people don’t understand how bad this can be. I saw two people today that had surgeries that were not very indicated. Both of them are way worse now then before they had surgery and the data and research holds that up, that people in chronic — I’m sorry, the other risk factor for — there’s several risk factors for increasing chronic pain after the surgery, but the presence of chronic pain before surgery is a big deal. The presence of great anxiety is a big deal. So what people don’t understand, the presence of prior chronic pain and an anxiety/depression, that surgery is very, very risky. It’s just not the definitive solution.
I mean it’s not like taking a car to the shop. I mean cars don’t have pain [inaudible]. It has nothing to do with the mechanical world at all.
Dr. Kevin Cuccaro: No, absolutely. Absolutely. Wow. Well, Dr. Hanscom, I’m keeping you here a little bit longer than I anticipated, but what I would like to do, would you come back for another episodes here? I think we could talk about all sorts of stuff in the future and I’d love to get into your DOCC project and some other things that you’re doing. Would that be okay?
Dr. David Hanscom: Yeah. I’d love to talk to you about the structured care approach. I have a lot of fun with that. It’s a very soft directed approach. And they can look at my website if they’d like. It’s backincontrol.com and the book provides the basis of the website. But the website evolved from my patients’ successes. We didn’t just make that one up.
It’s open source. You just have to hop on and look at it. That’s one thing. There’s also major implications of chronic pain on family issues and relationships. We could talk about that a little bit. And yeah, there’s a lot of things we could cover, so yeah, I’d love to talk about this stuff going forward.
Dr. Kevin Cuccaro: Fantastic. And what I’m going to do for this episode is I will have all those links to the website, as well as your book that’s available on Amazon. Very good book, by the way, folks. I used to prescribe it for patients who had back pain and were thinking of surgery. That was my prescription for them. I think it’s a great source.
And as I said, from your own personal experiences, not only as a complex spine surgeon, but as a patient with — who had had chronic pain, I thought it was just a great resource for them. So I look forward to having you back in the future.
And until then I hope you take care, and thank you so much for coming on the show with me.
Dr. David Hanscom: All right, Kevin. Well, thanks a lot.
Dr. Kevin Cuccaro: All right. Thanks. We’ll talk to you guys all soon.