July 2019 Edition. Volume XIX

The scalpel, is a potentially dangerous medical device.
Make sure you check out the operator of this device prior to its use.

The healing powers of “mother nature” are far superior to those of health care professionals. When disease allows the human body to get “off-track” it is the role of the health care professional to get it back “on the road” by the simplest and safest means possible.  If this doesn’t work out and incapacitation and disability progress more stringent and sometimes invasive treatments are required to return the patient to normal function.

Given the fact that 80% of the population experience at least one disabling episode of back pain during their lifetime it is clear that mother nature’s track record is quite good for the great majority of cases. When incapacitation due to back pain occurs it is important to note that the purpose of pain and spasm is nature’s way of keeping the individual at rest so healing can then occur.  Typically our desire is to thwart these wishes of mother nature, and in this way, a basic conflict is created. Bed rest is important, but only for a short period of time. Extensive bed rest has been abused in the past.  If after 2-3 days, supportive measures have not been successful intervention with the application of mobilization, manipulation, physical modalities, exercise, etc. needs to be instituted. Again, on a short-term basis (measured in weeks).  The true role of the ethical health care professional is to not only assist the patient in becoming better but also to assist them to become independent (not dependent) of the health care system. When the conservative approach is not successful, and  impairment and disability progress, it is at this point  that one begins to think in terms of possible surgical intervention.  If there should be progressive neurologic involvement or acute neurologic impairment such as a cauda equina compression syndrome surgery might even be an urgent, or even emergent, consideration.  When surgery becomes necessary the following questions then become pertinent:

How Does One Choose a Good Hospital?

Assuming the patient has a choice, the best way to compare hospitals is to visit them. Walk around a bit. Close your eyes; listen to and smell the environment.  Watch and observe how hospital personnel communicate with patients. See if they work together as a team.  You want a hospital where the patient is treated with consideration and made to feel like a guest in their facility. No matter how highly touted a hospital is for medical care if the patient is merely tolerated and treated in a shabby manner you don’t want to be there. Ask a hospital employee if they would be a patient in their hospital.

We are hearing more about mistakes being made in hospitals leading to patient injury and even death.  This is absolutely true.  It happens all the time but the incidence varies considerably.  The United States government reported that in 1998 there were 41,480 people who died from auto accidents alone.  Has this stopped us from driving?  No, although we may now spend more time being safer drivers. The same thing applies to hospitals, pick the ones that have the best safety records.  Just remember that stressed, demoralized and understaffed hospital personnel make more mistakes than those who enjoy their work environment.  As hospital staff reductions have increased throughout the country in response to reduced payments from HMOs and Medicaid (as well as sometimes poor hospital management policies) a near crisis among patient care professionals relating to job “burnout” has occurred.  Not good news for the patient. Yes, car safety is going up and hospital safety is going down.  If you want to feel a little better about today’s hospital situation rent the movie “Hospital” starring George C. Scott. Also remember that American Hospital care, with all its faults, is still the best in the world.

How Does One Choose a Good Spine Surgeon?

Most patients spend a great deal more time buying a car than choosing a surgeon.  Please believe that it’s worth the effort to be discriminating. While a  great deal of good information can be obtained from reference sources such the Marquis series of Who’s Who (Volumes on: Regional U.S., America, The World (i.e. Millennium Edition), the memberships lists of organizations such as the  North American Spine Society, the Joint Neurosurgical Committee on Spine, the American Board of Spine Surgery and other certifying institutions the very best way to check-out the quality of a spine surgeon is to ask someone in the hospital operating room. Call the hospital and ask to speak with an operating room supervisor (or operating room nurse, anesthesiologist or nurse anesthetist). Ask their confidential advice.  Tell them you are a patient considering having Dr. X be your surgeon.  Inquire if they would have Dr. X operate on them or a member of their family. It is rare event to not receive a candid and honest reply.  If the answer comes back in the negative inquire as to who they would choose for the procedure in question.

What about the Surgery Itself?

In the same way that one must open a door to gain access to a hallway a spine surgeon typically needs to remove some bone to gain access to the contents of the spinal canal. The bone usually removed is part or all of a lamina (laminotomy. hemi-laminectomy, laminectomy, etc.). It is possible to slip in between the lamina and gain entrance to the spinal canal without removing bone. Under some circumstances this works well but the main risk for the surgeon in doing this is to not have adequate exposure to do the surgery safely. In the world of real estate the bywords are “location’ location, location.”  In spine surgery the byword is “exposure, exposure, exposure.”

The most common spine operation performed is a surgical discectomy (removal of a herniated disc). Although there are many less invasive and minimally invasive procedures available the hard truth is that the standard surgical discectomy, utilizing operating telescopes (not operating microscope) and fiberoptic headlight illumination remains the most effective and cost effective treatment modality. Because of inadequate exposure many less invasive procedures may also require an additional standard discectomy to adequately address the problem.  This doubles the operative exposure, operating time and cost. Knowing when to appropriately utilize less invasive procedure is a matter of judgment based on the training and experience of the surgeon.

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