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AN ORTHO-PINION

Alan S. Hilibrand,  MD

Any views or recommendations shared in the Ortho-pinions blog are solely those of the authors and do not necessarily represent those of the American Academy of  Orthopaedic Surgeons.

Orthopaedic surgeons encourage “shared decision-making” when it comes to treating patients, because the doctor and patient each provide information needed to make a decision about surgery. The doctor can read the MRI and knows the medical risks and benefits, as well as the likely outcomes of the treatments he or she provides. However, only you, the patient, know how much the condition is causing problems, and the level of your pain. Only you know if the problem is limiting your daily activities. Therefore, it is very important for you to be specific with your physician in describing how much and in which ways your problem affects your day-to-day life, and for your surgeon to explain what you, the patient, can expect immediately after surgery and in longer-term follow-up.

Patients should understand that, in cases of traumatic injury (a fracture or loss of function due to spinal cord injury) and in situations where a patient is losing the ability to use an arm or a leg, surgery is often needed on an urgent (soon) or emergent (immediate) basis. However, most patients considering spinal surgery do so to treat their pain. Painful conditions sometimes improve over time even without surgery. On the other hand, delaying surgery months or years may result in worse outcomes and less recovery than when surgery is performed sooner.

In order to achieve the best result, you should make sure that you have followed two necessary steps in shared-decision-making for spinal surgery:

• Follow all of the nonoperative treatment recommendations of your physician.These may include medications, physical therapy, and/or injections. Even if these don’t relieve your symptoms, at least you will know that the problem was unlikely to go away with nonoperative treatment. It will also show your physician that you will follow his or her treatment recommendations.
• Provide the doctor with the most precise picture of your disability. Some physicians may require patients to complete a questionnaire that gathers this data from the patient. Make sure that your physician understands what you can and cannot do because of your condition, and whether you can see yourself living with this level of disability long-term.

 Physicians also have responsibilities in helping you decide if spinal surgery is right for you:

• Your surgeon should show you the anatomic problem as seen on imaging, and try to give you a sense of its severity.
• Your surgeon needs to relate this to you in a way that confirms that what they are seeing on the imaging strongly correlates with your complaints.
• Your surgeon should also explain the likelihood of your specific complaints improving after surgery. For example, if you have severe spinal stenosis on MRI, but are only experiencing mechanical back pain, then a lumbar decompression may make the MRI look better, but it probably won’t help you feel much better.
• Your surgeon should also explain the risks of the surgery, how much pain you will have after surgery, and how long your activities will be restricted.

So when does a patient decide whether to have a spine operation? Ideally, when the patient and physician both agree that: 1) the patient has significant anatomic compression that closely correlates with the symptoms; 2) the patient has attempted an appropriate course of nonoperative treatment; and 3) even with nonoperative treatment, the patient is still limited in many daily activities. Ultimately, it all comes down to open and accurate communication between the doctor and patient.

Learn more about Treatment Options for Low Back Pain.

This Ortho-pinion was originally written for A Nation in Motion, the AAOS's award-winning public awareness campaign dedicated to sharing the stories of people whose lives were improved by orthopaedic surgery.