LOWER BACK SURGERY

When to consult a surgeon?

(Keywords: LOWER BACK SURGERY, back surgery costs, leg pain after back surgery, chiropractic, lower lumbar back pain )

The honest answer: when all else fails and you simply have no where else to turn. And the pain or disability is so bad that you just can't 'live with it'.

And then only if the surgeon is absolutely sure he knows where the pain is coming from. You see, Medicine's own term is FBS: Failed Back Surgery. Their own research indicates that less than 50% of fusions for example can be considered successful.

A group of the world's leading orthopaedic- and neurosurgeons, with all the best tools and scanners available, concurred that they were less than 50% of the time absolutely sure what was causing the pain.



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Distressing...

Over the years it has been a sobering fact that I've treated some patients with lower back and leg pain, not succeeded and eventually referred them to a medical specialist. The report comes back: The MRI confirms that the problem was at a different level from the one I was treating. Had I had access to that information in the beginning, I'm convinced at least half the time I could have saved the patient from lower back surgery, and his insurance a vast sum of money. One, a dear friend, is a constant reminder of how I screwed up. I was adjusting the wrong level. And now, after multiple surgeries, her life is miserable...

It's stretching the point but say for example you came to me with a Carpal Tunnel Syndrome in your right arm, and I treated your left arm. Would the right arm get better? Of course not. Likewise, if your chiropractor, or the surgeon, is treating say the L4-L5 facet on the right when the problem is was actually at the L2-L3 facet, would the patient get better? Certainly not.

Thorough examination

For both the chiropractor and the surgeon there is simply no substitute for a careful, conscientious and painstakingly-thorough examination. If you think your practitioner, chiropractic or medical, is doing anything less, GO ELSEWHERE! Knowing "what and where" is absolutely crucial.

TREATMENT BASED ON A WRONG DIAGNOSIS IS DOOMED TO FAIL, be it LOWER BACK SURGERY or CHIROPRACTIC ADJUSTMENTS.


ON WHAT BASIS WILL YOUR CHIROPRACTOR MAKE HIS/HER DIAGNOSIS?


The Physical Examination: before LOWER BACK SURGERY

Carefully and thoroughly, your doctor should:


  1. RANGE OF MOTION: Take you through the ROMs of your lumbar spine. Simply discovering that it is right lateral flexion that cause the pain to shoot down the back of your right leg gives a huge amount of information.
  2. ORTHOPAEDIC TESTS: There are many specific tests that have been developed over the years to distinguish between a facet syndrome, a disc syndrome, a sacroiliac syndrome ... and the treatment for the three is quite different.
  3. WRONG DIAGNOSIS = INAPPROPRIATE TREATMENT = FAILED BACK SURGERY/ FAILED BACK CHIROPRACTIC.

  4. NEUROLOGICAL TESTS : Discovering that the numbness in the leg is in the groin and upper thigh, and not the side or back of the leg also gives us more vital information about the level of the lesion.


See how the ubiquitious Maignes syndrome can produce pain in the buttock, the side of the leg and the groin? Knowing exactly where the numbness is can make all the difference in arriving at an exact correct diagnosis: A facet syndrome on the right at L1-L2, or is it at L2-L3. Adjusting, or surgically treating the wrong level is doomed to failure.


MAIGNES SYNDROME CaseFile ...

REFLEXES and specific MUSCLE WEAKNESS

Likewise the reflexes and paresis of a particular muscle group give the clinician great insight into the level of the lesion. You can test yourself for muscle weakness...


4. Pain : Palpation of the segment can be very misleading, but it is one more tool that we use. If after all examinations there is still doubt whether the lesion is at L4-L5 or L5-S1, and L5 is very painful on palpation, then one might decide to go for the lower level.

5. Motion Palpation : This is where your chiropractor will excel since s/he examines every patient, looking for spinal fixations. Diligent motion palpation is a powerful tool, but it too is not always conclusive. In a severe disc lesion one may find no fixation at all, because the nucleus pulposis has escaped the confining ring-shaped 'annular' disc fibres. And sometimes an old injury resulting in a chronic fixation may give misleading information about the current problem.


Radiological examination:

X-rays are both very useful, and can be very misleading. This particular patient has three compression fractures at T12, L1 and L2, (assumed medically to be the source of his pain), and loss of the L4-L5 disc space (marked D), yet Motion Palpation, Kemp's Test and deep tenderness indicated that his pain was coming from the facet joints at L5-L1. A lumbar facet syndrome.


The proof of the pudding is always in the eating. Indeed adjusting L5 has decreased his pain and increased his mobility by 90%. This 64-year old man does his exercises faithfully, knows that he can't go on long dawdles with his wife when shopping, he will the one to drop! though a good 'wandel' is fine. He comes in every six weeks for his maintenance treatment. This man was under threat of lower back surgery, and is more than happy with Chiropractic... I wonder on which part of his spine they were planning the surgery! Where the fractures are? At L4-L5 where the disc space is reduced? Or at the actual level of his problem: L5-S1.


LUMBAR FACET SYNDROME ...

MRI SCAN

LOWER BACK SURGERY

It's widely acknowledged by radiological researchers that a significant (up to a third) of normal people with absolutely no back pain have bulging discs and abnormalities on MRI. Having said that, the MRI is a wondrous tool, fiendishly difficult to read properly, but it can make all the difference in coming to a sound diagnosis.

Unfortunately, an unethical surgeon, or chiropractor for that matter, looking for a fast buck can usually find something on MRI or X-ray that can be used to convince you that his/ her procedure will help you.



"It's critical to have a thorough workup — to get a sense of the root cause of your pain."

Arnold J. Weil, M.D.


FROM THE CHIROPRACTIC COALFACE: before LOWER BACK SURGERY



Yesterday I was consulted by a young man with severe pain in the back of his right thigh and calf. The pain started three months previously in his back for no obvious reason. As the pain in his leg increased, so lower back pain receded:

20% LBP / 80% leg pain, an ominous sign.

Worse, the "crossed" Slump test was strongly positive. Raising his LEFT leg produced severe pain in the back of his RIGHT thigh. SLUMP TEST ...

Aside: If the crossed sign is strongly positive, traction will always aggravate the condition.

He stood in an antalgic posture, stuck forwards and leaning towards the side of pain. The so-called Dejeurine triad was positive: coughing, sneezing and bearing down on the WC were painful.

Surprisingly there were no hard neurological signs: no numbness, normal reflexes and no muscle weakness.

The lowest segment in his back, normally L5, was exquisitely painful on palpation, and fixated on motion palpation.

Simple straight-forward diagnosis? Postero Medial L5-S1, Grade II lumbar disc protrusion.

Not so. One look at his X-rays show an extra lumbar vertebra (a so-called "lumbarisation" of part of his sacrum S1, with loss of L4-L5 disc space. So, is the problem at L4-L5 or L5-L6 or L6-S1? X-rays point to the higher level, examination to the lowest. The presence of the anomaly makes the pain pattern to the back of the thigh less certain. Today he has a MRI scan, out of his own pocket because his doctor has refused to order a scan.

Knowing the level of the lesion, with a high degree of certainty is critical to a successful outcome. Three months of medical management (neglect frankly, in my opinion) has seen him get steadily worse. Can Chiropractic still mean something for him at this late stage? Or is it lower back surgery?


What's on his side is that the Postero Medial disk herniation usually responds better and quicker than it's more common first cousin, the Postero Lateral Disk herniation. POSTERO MEDIAL DISK HERNIATION ...

4 days later we have the MRI

It came as no surprise. A large lumbar disc protrusion at L5-S1, the lumbarisation, the list to starboard, and the pinched nerve in the foramen. Exactly what the physical exam predicted.


See how the young man has an antalgic list TOWARDS the painful side. What I call the Pisa sign. This is typical of the postero-medial disc herniation. Exactly what I expected.


Here you can see the large bulge into the foramen trapping the nerve to the back of his right leg. No wonder he has so much pain in his thigh. This is sore. Ouch!


This is a serious case. Medicine says we have no business dealing with a case like this. He should go straight under the knife.

I give him a 50/50 chance of escaping surgery. Everything is dependent on "does he trust me". Will he go the distance, or will family and friends, his doctor, pressure him? One sneeze, one silly movement can change everything.

Minus: He had a lot of pain after the first treatment, and had to call his doctor in for a shot.

Plus: Today, lifting his left leg produced no pain in his right leg. He too noticed it straight away. But, he's on heavy medication.

My take? He's definitely a bit better, but it's a knife edge. This is what makes Chiropractic so exciting. The challenge, the human drama. Never bored, I'm exhausted 's avonds. I'm a Dutchman. In the evening.

When he's at home, he SHALL follow these rules to the T. No set backs is the rule: SLIPPED DISC RULES ...



LOWER BACK SURGERY COSTS

Americans spend $86 billion on back treatment every year, roughly the same as for cancer, a very large slice of which goes towards the back surgery costs. However research confirms that the problem is getting worse not better despite all the moola spent. Discectomies and fusions are soaring, over one million per year in the USA, yet more and more people are disabled and miserable.

8% of patients have a second surgery within two years; and 20% within ten years. Less than half of fusions are appropriate and successful. At a cost of $75,000 each...

CHIROPRACTIC COSTS

I give the young man in the case above about a 80% chance of full recovery, if he sticks with the program. He has a surgical consult in a month, and I have to do a miracle before that. 80% is admittedly a thumb suck, but based on thirty years experience. The direct cost?

Acute phase: 2/w for 4 weeks = 8 treatments.

Rehab phase: 1/w for 3 weeks = 3

Tailoring off 1/w 2 weeks = 2

Maintenance: 1/6w for 40 wks = 7

20 treatments in one year @ €43 = €700 - €1000

The "intangible costs" are more difficult to measure. He has his own computer business and will be completely out of action for at least a week, as he may not sit, not at all. Thereafter he will most likely be able to perch and do some time on his computer. In total he is probably going to be disabled and unproductive for 2-3 weeks. One sneeze can change everything...


Prestigous medical journal "Spine"... LOWER BACK SURGERY

‘Spine’ is probably one of the most esteemed medical journals in the world. Spine has reported that, in a randomized controlled trial or RCT (one of the benchmark Chiropractic research trials) of patients with chronic back and neck pain, after 9 weeks of Chiropractic treatment 27% were completely without pain. In comparison only 9% of patients who received acupuncture and a miserly 5% of patients who took prescribed medication were pain free.

In another Spine research article Aure et al showed that in a group of 49 patients with chronic low back pain, preventing them from working, that 67% of those receiving manipulation were back at work after two months in comparison with 27% who received exercise only.


CHIROPRACTIC RESEARCH @ Bernard Preston.com ...

CHIROPRACTIC RESEARCH @ Chiropractic-Books.com

Lower back surgery risk factors

  1. SMOKING: As in all surgery, smokers are at higher risk of Failed Back Surgery syndrome. There just isn't enough oxygen for the tissues to heal properly. Add to that the atherosclerosis narrowing the blood vessels. Add to that the coughing... And then of course you're at much higher risk from the General Anaesthetic if you are a smoker.
  2. Every Chiropractor will tell you how s/he dreads the acute low back and leg pain patient who is also a smoker. The chances of chiropractic helping, are also reduced...


    ATHEROSCLEROSIS SYMPTOMS Low Back Pain ...

    ANAESTHETIC ALZHEIMERS ...

    GENERAL ANAESTHETIC ...

  3. OBESITY. Presenting his research done at Jefferson University hospital, neurosurgeon Dr John Ratliff found a much higher incidence of complications in extremely overweight and obese patients, including blood clots, wound infections, heart problems, and deep vein thrombosis. “We found that the incidence of complications related directly to the degree of obesity,” he says...
  4. DIABETES. It's well known that diabetics, particularly poorly controlled diabetics, have a higher risk of wound infection and complication in all forms of surgery. Consider walking benefits both to prevent lower back surgery and maintain better blood sugar levels. A leg length inequality should be considered if standing and walking increase the pain...
  5. WALKING BENEFITS ...

LEG LENGTH INEQUALITY ...a short leg?


BACK SURGERY COSTS

When considering lower back surgery costs, one must also count in the hidden costs: the months of sick leave and loss of productivity, the decreased enjoyment of life for the patient with lower back pain, the rehabilitation, and the burden borne by the whole family, when one member goes 'man down' for a few months. Read more in this report: LOWER BACK PAIN ...

LEG PAIN AFTER BACK SURGERY

If at all possible avoid LOWER BACK SURGERY

I don't pretend to have the statistics as to just how often leg pain develops AFTER surgery (I'm on the hunt for them and will update this page accordingly) but in practice one is fairly regularly faced with patients who either got little relief of leg pain, or temporary relief, or leg pain started after surgery.

Can that happen with Chiropractic too? Yes, it can, though the incidence in my own practice is low, and almost always of a temporary nature. Chiropractic researchers are now busy gathering statistics of this nature so that we have a much clearer science-based answer, rather than a general thumb suck. LEG PAIN after BACK SURGERY ... ( showthread.php?t=380350 )

TO SUM UP... LOWER BACK SURGERY.

I'm personally in principle not against good lower back surgery based on a sound diagnosis, after all else has been explored, and in the hands of a careful and experienced surgeon. I refer patients myself for surgery occasionally when it's clear that Chiropractic is not going to help.

A surgeon would probably say: ... I not against Chiropractic care ... in the hands of a careful and experienced chiropractor...

How do Chiropractors and Surgeons become competent and experienced. The hard way, I'm afraid. We don't call it 'a practice' for nothing. We practice on you!

Careful, thorough and conscientious are not necessarily qualities that one gains with experience. I personally think that all patients, no matter what condition they have, should be asking themselves the question: "Is this doctor, chiropractor, surgeon... being careful, thorough and conscientious?" If you're unsure, vote with your feet!



"A teacher is one who makes himself progressively unnecessary."

Thomas Carruthers

A good doctor too.


COMPLICATIONS OF SURGERY

Before going for lumbar back surgery it's worth giving chiropractic treatment a solid try. At least a month. Obviously there are exceptions... COMPLICATIONS OF SURGERY ...


LOWER LUMBAR BACK PAIN

Avoid LOWER BACK SURGERY

Successfully addressing chronic lower lumbar back pain in the chiropractic clinic usually means addressing numerous factors: a short leg, spinal and sacroiliac and hip fixations, poor muscle tone, obesity, smoking, posture and work situations... all contribute to back pain. LOWER LUMBAR BACK PAIN ...

The above case...

Fortunately there were two people very determined that he wouldn't have lower back surgery. He and I. Despite the pain he needed no encouragement to go the distance.

Unlike medicine in chiropractic the patient is very involved in the healing process. It's not just a case of take a pill, and go on with your life... it's vital that you follow instructions to the letter, use your common sense. In a sense it's your own body that is the healer, all we are doing is aiding and abetting that process. Refusing to do the exercises faithfully, to stop sitting, even one good sneeze can ruin everything.


Prevention is the key...

USEFUL LINKS @ LOWER BACK SURGERY



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Interesting challenges of the day

1. Mrs D, a 78 year old woman has very severe sacroiliac joint pain, and even more severe cramps in her right leg. There are two problems; she is on two diuretics but no slow K. Taking her temporarily off one diuretic and adjusting the SIJ brought 50 percent relief within four days. 

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has  two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?


Interesting questions from visitors

CLS writes:

Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

Your own unresolved problem. Pose a question

Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.


You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.

The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.