In the 1974 Warner Brothers spoof Mel Brooks directed “Blazing Saddles” Alex Karras portrays “Mongo” a not-too-bright, but well-intentioned goliath of a cowboy. The “Me Mongo, Me Fix” mind-set has not been just unique to the Mongos of the purple sage alone. It is, unfortunately, alive and well in the medical community; particularly evident in some surgical practices. The discipline of surgical spine care is rife with examples of the “Mongo Mind-Set” where surgical procedures reflecting poor understanding of the subject, combined with a immense urge to exercise often ill-advised surgical prowess can result in creating more problems-than-benefits for patients. One then wonders how often the Hippocratic dictum “first of all, do no harm” and the Razor of Occam has been overshadowed by the Mongo Mind-Set reflecting only unbridled surgical zeal?
Me Mongo, Me Fix
Although it was actually Hopkins neurosurgeon Walter Dandy who first described the herniated lumbar disc in 1929 credit for this discovery has was given to Mixter and Barr in 1934 when the medical profession subsequently became fixated with disc herniations (to the exclusion of other spine pathologic entities). The phenomenon of “Me See Herniated Disc, Me Fix” has become emblazoned into the surgical consciousness. By simply “fixing” disc herniations and not inquiring as to the reasons as to why discs herniate (as well as other accompanying significant pathology) many back patients have joined the legions of those “who never seem to get well.” The universal failure of back surgery patients to do really well long-term in the 20th century (for many reasons) has become the stuff of legend.
The “Me Mongo, Me Fix” approach had led to the creation of legions of “Failed Back Surgery” patients. The most common reason for this has been the failure to either identify, or to adequately treat, lateral spinal stenosis. Other reasons are multiple including ignorance of genomic spine disorders, even when such is evident to the knowledgeable eye on imaging studies. Next to the management of the “herniated disc” the most common surgical transgression in the Burton Experience has been the “Me Mongo, Me Fix” approach to a degenerated intervertebral disc (sometimes referred to as a “black disc” because of it’s dehydrated appearance on a Magnetic Resonance Imaging [MRI] study). There are those who assume that because a disc is black on MRI it “needs to be fixed” surgically. Often this results in a multi-level front and back instrumented rigid fusion which many not address to initial patient problems and may also serve to compound and advance adjacent disc degeneration. Degenerated, or black discs, are a normal sequela of accumulated insult and injury as well as the gestational and aging process in addition to the liability of cigarette smoking. Only when these changes produce disability and incapacitation is a true disease created.
The film to the left is of a young patient with multilevel degenerated discs due to a genomic condition, juvenile discogenic disease. The primary treatment provided was a 5 level 360o fusion with pedicle screw and rod instrumentation. The patient was not improved by this surgery and left with few other viable treatment options. In addition, because of the extensive instrumentation additional non-invasive imaging studies such as Magnetic Resonance Imaging (MRI) were not possible because of the high level of artefact produced from the ferrous metal.
This retired nurse was diagnosed as having “multilevel degenerative changes” and a “mechanical back syndrome.” Her primary treatment was a posterior decompression and 3-level instrumented pedicle screw fusion with anterior interbody placement of bone grafts. She was not clinically improved. After one year her instrumentation was removed. She was still not improved. At this point her surgeon recommended a morphine pump or an implanted spinal neurostimulator to control her disabling pain.
In the cases shown above the “Mongo Mind-Set” was in effect. The primary treatment for both of these patients should have been of a non-surgical nature. How can one explain this ill-advised surgery? Is this a reflection of lack of knowledge or training on the part of the spine surgeons involved? Is it an example of “feral” surgeons who prey on patients? One can never be certain.
Unless the reasons for surgical intervention are urgent initial conservative care is always indicated. With appropriate non-surgical treatment the Burton Experience has been that few of the types of patients shown above require surgical intervention. In fact, performing multi-level fusion to treat pain associated with degenerative disc disease has been identified as the single greatest case of excessive and unnecessary spine surgery in the United Staes today. If surgery becomes legitimately indicated, it should be as minimally invasive as possible and reflect modern surgical advances and appropriate to the patient’s actual needs.