Please contemplate the following metaphorical imagery:
‘What is he on about now’, I hear you say.
The image on the left is a view from a downstairs window and is idyllic.
The image on the right is a view from a top storey window looking down over a rather polluted and dingy city.
The message I am trying to convey in relation to persistent pain is an indelible impression I keep having on a recurring basis as a result of my (over 2000) detailed compensation case reviews. Actually these case reviews are remarkably similar in many ways; I often quip that they are like movie scripts with similar plots and endings, but just different names in the rolling credits.
People get injured, or simply develop pain with no actual trauma as such, and their journey begins through the medical / surgical management process. They undergo the usual investigations and various doctors, therapists and surgeons get involved.
And here it is – almost all treating practitioners think that they on the whole are doing a great job. Almost all believe that the responses to their interventions are positive and successful. And much as I am reticent to point fingers, I feel compelled to indicate that surgeons are over-represented in this observation.
The view ‘from a higher floor’ of the entire case and clinical pathway is consistently nowhere near as idyllic a scene as the view from a single downstairs window.
Now, everyone seems to acknowledge the undeniable statistics that persistent pain has increased remarkably over recent decades in Western Society despite modern health systems, and post-surgical persistent pain is a large part. So if everyone is doing such a good job, how come this is the case?
Furthermore, when I discuss this topic with various practitioners, they blow their own horns happily and usually blame others for poor management processes –
ie: ‘he (or she) done it!!’
Like in the school yard … remember?
In fact, it has been my overwhelming observation as a medico that the health professions in general are actually quite proficient at blaming others within and without for all sorts of problems and poor outcomes. Medicos slag (sorry – criticise) each other quite often and with little provocation. And then this extends easily to other non-medical craft groups.
In particular, my conversations with surgeons about poor outcomes are almost always accompanied by confident assertions that their outcomes are excellent with happy patients and that the bad results are being achieved by others less capable.
But everyone seems to say the same thing … including me!
It is a bit like the thing that patients always say about having a ‘high pain threshold’; I am yet to hear anyone who admits to having a ‘low’ pain threshold. (NB: actually when one understands pain neuroscience properly this statement becomes so much more interesting!)
Very commonly, I have documented cases when a post-operative review reports positive and sometimes even excellent results virtually simultaneously with other records and other examination reports reporting very poor outcomes.
And few, if any, do proper audits.
And when, audits / studies are done they are based on ‘patient reported outcomes’.
I wish I had $10 (inflation has hit because the expression used to be $1) for every time I have personally assessed or case reviewed patients who perceive their surgery very positively yet every objective parameter depicts precisely the opposite. They seek more surgery. A recent case I recall was a poor fellow who had two cervical spine surgeries over several years and was upset that his third (extending his fusion above and below the several levels already fused for similar degenerative changes) had been denied for payment by his insurer. This fellow had never achieved any meaningful return to function and was on a morphine equivalent of over 200mg per day (??! – IMAGINE BEING HIS ANAETHETIST AND MANAGING HIS POST-OP ANALGESIA!) with minimal effect. But he quite confidently told me that his surgeries were successful and he was keen to have another. His pain sensitisation was off-the-scale as I couldn’t even touch him and he could barely move, but his surgeon was keen to have another go. I am confident this fellow would have ticked the positive box in the ‘patient reported outcome’ form in a study and rated his surgeries highly; this is what he told me directly was his perception.
I wonder whether many simply do not want to invalidate their own poor decision making and/or are not keen to criticise their charismatic surgeons who offer hope … again and again and again.
Perhaps others have low ‘minimum acceptable outcomes’ and any relief no matter how temporary or minor is perceived positively.
I suspect most respond positively via a placebo construct.
At this point, I will remind all again of the game-changing research relevant to placebo controlled surgical trials in eg: knee arthroscopy.
FINALLY, surgery is being subjected to the same rigorous research process as medications ie: via placebo / sham / fake surgery comparison controlled trials. What this has importantly discovered in knee arthroscopy surgery is the following – a very widely performed procedure with almost unequivocally positive outcome studies based on patient reported outcomes (PROs), and with minor complication rates, is now highly questionable if not completely debunked.
I think it is a fair observation that patient reported outcome results in spine surgery are not as positive and uniform as those seen in knee arthroscopy trials and there is a significantly higher complication and persistent pain outcome rate.
To my way of thinking this extrapolates easily into a mandatory requirement for serious interrogation and re-interpretation of the existing supportive ‘best available’ data and accepted research methods for spine / other surgery interventions for pain. PRO studies of various quality are consistently presented as robust ‘evidence’ in support of surgical pathways despite poor support in systematic reviews. The same people who confidently present such data heartily criticise other less harmful craft groups, eg: chiropractors, who present similar methodology with patient reported outcomes and comparative treatment research.
But, as I was advised recently by an eminent spinal surgeon on this topic, who was very confident of his own non-audited results and was quite critical of other less experienced or proficient surgeons bringing the profession into disrepute (‘they done it!!’), “everyone knew that about knees, but spines are different … !!”
References to consider include:
- Spine surgery outcomes in a workers’ compensation cohort – Harris et al. ANZ J Surg 82 (2012) 625–629
- The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Jacobs et al. Eur Spine J. 2013 Sep;22(9):1936-49
- Epidemiology chronic pain. Croft et al. 2010 (Oxford University Press)
- Failed back (surgery) syndrome: time for a paradigm shift. Vleggert-Lankamp et al. British Journal of Pain. Feb 20, 2013
- Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Thorlund et al. BMJ 2015;350:h2747
- Use of placebo controls in the evaluation of surgery: systematic review. Wartolowska et al. BMJ 2014;348:g3253 doi: 10.1136/bmj.g3253 (Published 21 May 2014)
- Belief reinforcement: one reason why costs for low back pain have not decreased. Zusman. Journal of Multidisciplinary Healthcare 2013:6 197–204
- Assessment of spine surgery outcomes: inconsistency of change amongst outcome measurements. Copay et al. The Spine Journal 10 (2010) 291–296
- Bias in Surgical Research. Paradis. Annals of Surgery. 2008;248(2):180-188
- Twenty-year perspective of randomized controlled trials for surgery of chronic nonspecific low back pain: citation bias and tangential knowledge. Andrade et al. Spine J. 2013 Nov;13(11):1698-704
- Minimum acceptable outcomes after lumbar spinal fusion. Carrragee, Cheng. The Spine Journal 10 (2010) 313–320
PS: I wrote this blog last night. Just today I did a case review at work and to cut a very long story short here is some info and some exactly reproduced de-identified quotes:
The injury was due to simply straightening from a bent position in Sept 2011. Early MRI etc… And waddya know but the circumstance investigation report revealed that a bullying accusation had been lodged a few days previously with the employer. This finding was not noted by anyone else in the worker’s pathway.
Context versus ‘pathology’.
Surgeon IME (independent Med Examiner) October 2011: “I do not recommend any change to the worker’s current treatment. I believe that because of the pre-existing degenerative disease and also his functional response to my examination, it is likely that he would have prolonged symptoms irrespective of the type of treatment he received. The surgical treatment recommended by xxxxx is reasonable and appropriate. However, I feel that it is likely that he will continue to have symptoms even after an apparently successful operation …”
The worker had had no specific pre-operative conservative management apart from rest, investigation and analgesia.
Surgery was then done in November 2011 (NB: approx 2 months post onset of pain) in form of L5/S1 instrumented fusion etc despite highly discordant clinical features, no objective radiculopathy and relatively minor MRI changes; certainly no overt neurocompression was reported, only ‘contact’.
Occupational Physician IME May 2012: “Postoperatively, Mr XX stated he has been troubled by ongoing pain in his back and down the right leg …” . There was no mention of a period of relief and there was no functional recovery in this 6 month post-op period. Strong analgesia requirements continued.
Medical report from Surgeon May 2013: “The indication for the surgery was L5-S1 spinal stenosis. He had an early excellent response to the surgery with resolution of previously intractable right sided sciatica, however despite good initial progress unfortunately his right sided leg symptoms subsequently recurred at 4-6 months postoperatively …”
Definitely an excellent result.
I think you can imagine how this worker is doing now in 2015 –
I attained Fellowship of the Australian College of Sports Physicians in 1995 and have gained extensive experience in this field both before and after that milestone. I worked for five years in the Victorian snowfields, before joining the Melbourne Football Club (AFL) in the mid 1990’s. I was a medical officer there for a total of 15 years with Dr Andrew Daff, as well as another 2 years with the Collingwood Football Club in the VFL. I was appointed as the AFL Australian International Rules team doctor in 2011 and 2013. I have also supported other elite sporting teams including the Australian Diamonds netball team in 2012. My main current appointment is with the TAC and WorkSafe as a medical advisor on the Clinical Panel and on various projects, and I am also an Independent Medical Examiner. In addition to general sports medicine I have developed a particular interest in the neuroscience of pain, the potential to ‘de-sensitise’ persistent pain, the biopsychosocial management model and exercise & conditioning prescription. View all posts by kalfried