Why do Spine Surgeons Recommend Different Surgeries?
If you suffer from back pain and have exhausted 6+ months of conservative therapies, such as physiotherapy, chiropractic adjustments, medications and injections, then the next step may be to speak with a spine surgeon.
Before a consultation, an MRI, CT scan and X-ray imaging are routinely completed, as these images will allow the surgeon to look for pathological findings that correlate with your symptoms.
The priority of the spine surgeon will be to:
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Ensure you are safe, that your spine is stable, and that the delicate nerve structures inside and surrounding your spine are not at risk.
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Ensure you have the best possible quality of life.
Yet, this is where it can get confusing, because more so than in any other surgical specialty group, different spine surgeons might recommend completely different treatment plans, for the same patient, the same diagnosis, and at the same moment in time.
5 Reasons Why Spine Surgeons Recommend Different Surgeries
1. Where it all began: University and Teaching Professors
University hospitals are places of research, learning and innovation, and where surgeons develop and hone their surgical skills and patient care experiences. Philosophies, methods, and techniques can differ between countries, universities and teaching professors, including their philosophies.
2. Extended Training & Further Specialization
A fully qualified spine surgeon may want to specialize further through fellowships. Such fellowships may include advanced techniques and skills with different approaches to the spine, such as the anterior approach (through the abdominal cavity), posterior approach (through the back) or lateral approach (through the side). Each approach has unique risks and benefits. The surgeon may attend workshops abroad, or even a lengthy fellowship under the guidance of a senior surgeon considered an ‘expert’.
E.g. The anterior approach required for lumbar disc replacement requires a great deal of vascular preparation, which some spine surgeons may not have the specialized training to navigate. Instead, these surgeons may prefer the lateral or posterior approach.
3. Available Technologies and their Limitations
Available technology is highly influenced by government health regulatory bodies, in addition to medical research. One example is The Food and Drug Administration (FDA) in the USA, where the 3rd Generation Artificial Discs are not yet approved for surgical use, while they are approved in other countries with an advanced healthcare system i.e., Germany, France, Switzerland, the United Kingdom, and Australia.
Another example is the TOPS FACET Joint Replacement System(made in Israel) which is used by some German surgeons but is not yet approved for use in Australia or New Zealand, even though surgeons from these countries have shown interest in this device.
Before allowing new surgical devices to be used, government health regulatory bodies will be cautious and will want independent clinical trials that demonstrate both efficacy and safety. This requires finding hundreds of patients with almost identical spine damage, to receive the same surgery, with outcomes measured over many years.
4. Experience and Confidence
Surgeons may have performed a certain technique only a few times or they may have performed it thousands of times. If they are honing their skills in a new surgical technique, they may be less likely to accept more complex cases, in the best interest of the patient.
One example we regularly observe in medical decision-making is when a previous posterior decompression surgery (like discectomy and laminotomy) is considered a contraindication for Artificial Disc Replacement (ADR) due to the risk of scar tissue from the previous surgery. This is not the case says ONZi, who reports that ~ 50% of their lumbar ADR patients have had some type of previous posterior decompression surgery.
A surgeon will recommend the best surgery for their patient according to their knowledge, opinions, and experience. Questions are welcomed, as are second opinions. Mutual respect is the key to maintaining a solid doctor-patient relationship.
5. Surgeon’s Philosophy
Surgeons are not robots. They are real people, whose personal philosophy can play a part in advising for surgery. For instance, a surgeon may feel that conservative treatments have not yet been exhausted and thus, surgery is not yet indicated.
Another example is where a spinal fusion is necessary, a minimally invasive decompression surgery may be offered first. However, where a motion-preserving solution with a new generation implant can be offered, then the smaller ‘symptom treating’ surgeries will be disregarded. Patient age, underlying medical conditions, and quality of life are contributing factors.
A final example, debated at the 2017 EUROSPINE Convention in Dublin, has been the topic of “Lumbar Disc Herniation: Do We Operate Too Early or Should We Operate Earlier?”. Compelling arguments were presented from both sides.
So How do I Know Which Spine Surgery is Best for Me?
With the 5 points above, it will be easier to understand how spine surgeons can recommend different surgeries. Yet, it is important to receive, and investigate multiple, independent specialists’ opinions before proceeding with any invasive surgery. This is something ONZi supports 100%. Independent means that the surgeons are not affiliated.
Additionally, it is important to have as many details as possible to be able to make an informed decision. Outside of speaking with multiple specialists, this can include the completion of personal research, speaking with former patients, asking hard questions, and discussing your options with a trusted, primary care practitioner.