Thank you for this clear-eyed reporting on an issue within our American health care mess. We are still convinced doctors are infallible wizards and the next wonder pill or “innovative” medical device will be our silver bullet to health. In this way we enable the worst in health care costs, propping up markets for procedures and drugs that are unproven but wildly priced—and a “system” of health care immune to regulation.
7
"And last month he won the Masters, playing the way he used to."
Actually he played nothing like he used to. That made it all the more impressive. He used to be able to overpower a golf course. He won the Masters with intelligent shot-making, risk management and layups when appropriate.
4
I had spinal fusion surgery 38 years ago to treat spondylolisthesis. Back then my surgeon gave me advice that I have always tried to maintain - keep my weight as close to ideal as possible, exercise (swimming) and eat to care for my bones (calcium, etc.) I do have arthritis in my back now as the result of the surgery, but I should add I have a physically demanding job (greenhouse) and use my back in ways that I really shouldn't. On balance it was worth it.
5
The one constant I see in articles like this is lose weight.
11
We are in the era when eponyms are applied to operations that succeed in extending a “super star athlete’s career, and then become a marketing tool for the procedure. “Tommy John” surgery comes to mind.
This article is a valuable contribution to the need to inform the public how uncommon ,if not rare , Tiger Wood’s result from spine fusion really is. As the article reports: without his athlete’s body and motivation, surgery alone would probably have failed.
If this piece gets the attention it deserves, it is likely “Tiger “ surgery will not become a euphemism for marketing this procedure to those with chronic pain. It must be remembered that if “ only fifty percent of patients achieve a thirty percent reduction in pain”, that means a sufferer can predict their own result by simply flipping a coin.
Given the proven results of time, physical conditioning, and long term rehabilitation, it is time for insurance companies to fully compensate physicians,physical therapists and strength “conditioning trainers” for the 6 to 12 months of therapy that can produce results equivalent to spine surgery.
10
Had a fusion five years ago. It changed my life from impractical to unbearable for three years, but with time , my condition has improved to 'travesty'.
Two things i wish I had known .
Never compare chronic 'lift and carry' injuries or outcomes with sports or auto injuries. If you are a working stiff for over 40 years like me, you will never get Tiger Wood's results.
And,secondly , if you are not a celebrity, you are in trouble. Back problems are difficult, and there is no motivation on a 'nobody' case like mine- just the drudgery of trying to extract the same money my insurance company is dedicated to saving.
And , no, I'm not obese or belligerent. I'm just a faceless body that'll never covey notoriety regardless if you cure or kill me. And I don't blame you , I know your group says you were supposed to tend 50 patients today.
26
Add my voice as another fusion patient who got over 50% improvement and am fairly active at 66ys old. I KNOW how hard Tiger had to work to regain, relearn his game. His talent is undiminished but putting the mechanics back together after this surgery is a phenomenal achievement. I've been watching and rooting for him all along and cried when he won the Masters. You go Tiger....age will eventually catch up to you, but in the mean time I hope you continue to enjoy success.
9
Maybe this is also a story of the back being a metaphor for life. As a physician who worked previously at a prestigious spine clinic many years ago, it became obvious that back pain and the very limited success of spine surgery are integrally intertwined with the patient's life experience past and present.
Maybe TW after many years of sex addiction, prescription drug abuse for his aching back and drunk driving which all paralleled his severe decline in athletic performance forced him to search for his adult soul. He appears to have found some 'back stability' through cleaning up his life and possibly a little help from his spinal fusion. A metaphor in itself that: "supports (fuse) one's back (past) life". The fact that he won the "Masters" is a beautiful reference to his return as an older man. Cheers.
8
I'm a therapeutic bodyworker & yoga teacher who works with many clients with back pain, & to whom a local pain management doc refers. In my experience, both personally & professionally, many people end up with back pain due to lack of flexibility. The back has five layers of muscle, which are progressively smaller & do more precise movements layer by layer. The fifth layer, or that closest to the skeleton, are those that connect rib to rib, and vertebrae to vertebrae & need flexibility to keep up.
A recent example: a 65 year old gent with right low back pain referred by the pain doc. He'd had three cortisone injections which had helped not a whit. When I met him, he told me he'd also had a left hip "cleaning", a relative less-invasive surgery to cut away scar tissue & clean out the joint. This, in fact, was from where the pain emanated to his right low back. In three weeks, his right low back was no longer hurting. It was his left hip. Took me another two weekly appointments & a very involved spouse who stretched him out several times a week, to bring him to a place where his pain is non-existent. It always strikes me (& this is a conversation I've had with the pain doc several times) that allopathic doctors believe that the pain is where the patient experiences it. No, it isnt.
I'll never understand why stretching isn't more valued. It works, with consistency. Ida Rolf said: where the pain is, it isn't. Words to live by.
9
One question is how long does fusion hold up in normal living. Another question is how long will it hold up for Woods given the high stress he puts on his spine every time he swings the club. Golf is not a back-friendly sport, especially at the professional level.
4
@macduff15
If you watch Tiger Woods, you'll see that his swing has changed, by necessity. He now rotates functionally: from his thoracic spine. This is the oxymoron of spinal rotation: functional rotation takes place through the rib cage, the most stable part of our spine, not in the lumbar, where most golfers jam their backs to create torque. This change will hopefully give Tiger more years of excellent golf. Would that differs would see it and learn.
4
I am one of the people referred to by Dr Reitman as “missing mechanical support” for my lower back. For me, surgery was a life saver. Throughout my adult life, I have been athletic and slender with good core strength. About five years ago, I developed debilitating pain down my left leg with sitting. Over time, the pain worsened until I could hardly walk if I had been sitting. The pain was in my leg but never in the back itself. I went through almost two years of physical therapy, but the exercises and stretching made it worse. I saw a chiropractor and the adjustments made it worse. Finally, my internist ordered an X-RAY and MRI and referred me to a neurosurgeon. The tests showed my L4 vertebra was moving over 15 mm out of place when I bent forward. I had spondylolisthesis and it was the sole cause of my issues as the tests showed all of my discs and the rest of my spine were healthy. The surgeon recommended a fusion to stabilize the L4 vertebrae. The second specialist I consulted agreed that I needed surgery to feel better. Ultimately I had an anterior fusion at L4-5 done at a major medical center. My recovery was quick and the pain is gone. In the two years since the surgery, I have returned to athletics, including weight/core training, swimming, biking and jogging. The fusion stabilized my back when no amount of exercise or therapy could.
15
@Diane Ramthun
Good for you, glad it worked for you. There are many types of back pain. Like you, I tried everything, and nothing worked. When the pain became unbearable, surgery was my only option. I had spondylolisthesis. Therapy and core exercises are not going to fix this.
My surgery was a god send, and now I live almost pain free.
The bad thing about this article is that too many leap to the conclusion that all back surgery is bad. It depends on the condition. In some cases (like mine) , surgery is the only chance for a normal pain-free life.
Be aware and don't overdo it and break it again, like I did.
4
@Edd I too had spondylolisthesis and spinal stenosis and could only stand upright for a few minutes after the pain progressed over 3 years. After L4-5 laminectomy and spinal fusion. I was able to walk to the bathroom unaided the day of surgery and was discharged from hospital on the 2nd post op day. I have been pain free from the 2nd week after surgery and bless my surgeon and the operation daily. Without this operation I would have eventually been paralysed and incontinent. Some back surgeries are necessary and successful.
5
It is so disappointing to know that doctors are only too happy to put a patient under the knife. My good friend, 68, overweight, just had this surgery performed. She had terrible pain for a few days (which the doctor did not prepare her for). But the doctor did promise a full and total recuperation - and no more pain.
Unfortunately, it never occurred to us to consult with a physical therapist. She sought 4 opinions, all surgeons, and all said the same thing.
3
I am 58 and in good health. My sport is fencing, which is generally very kind to the body because there is a lack of the lateral/twisting motions that you have in basketball and various racket sports.
I developed some persistent but not debilitating pain on one side of my neck. A trip to the ortho clinic (we have some of the best) confirmed that I am... old. "you have arthritis and disk degeneration consistent with someone your age". This young smart doctor discussed the various options but suggested a combination of massage, dry needle therapy, physical therapy, and a prescription muscle relaxer for several days.
This was sound advice but still seemed like overkill. I took a week off of fencing, used a hand vibrating massager, and took some ibuprofen. Problem solved. VAST savings in various fees and prescriptions.
I'm still old, and I know I'm lucky physically (although I do work at staying fit and flexible), but we still have a way to go in managing care/costs.
5
Unfortunately for patients, getting approval for months of physical therapy from most insurance plans is much more difficult than getting approval for surgery. Our medical system is geared toward the high tech, highly invasive quick fix rather than slow work to help the body heal itself.
20
I am a retired physician with several decades history of back pain, attributed to lumbar spinal stenosis (LSS) not to disk disease.
I had trials of physical therapy and epidural steroids without significant benefit. After a while, I found that the more I moved, the less pain I experienced
Until 2014, no physician (including a spine surgeon) recommended surgery. In that year, I first developed pain and numbness indicating compressive radiculopathy.
At that point, my spinal surgeon and a second opinion spine surgeon he recommended agreed I should have laminectomy at three levels.
Because al non spine surgeons I consulted felt back surgery was a last resort choice, I sought a third opinion at a clinic in the Midwest. I also reviewed published data from the “SPORT” study which was the primary basis for claiming that surgery was superior to non surgical management. That study was small (259 patients) and flawed in a number of ways.
The doctors at the third clinic did not recommend surgery and I continuing on without surgery at this time.
LSS is generally slowly progressive, so in the absence of a disk problem, I may continue on until satisfactorily until the end of my life. Or, my symptoms may become so aggravating and limiting that I may seek out surgery.
Or new techniques (or medicines) may promise high rates of “cure” without side effects or the need for extended rehabilitation.
No one answer for all with “back pain”.
6
I am a victim of the type of ill advice depicted in this article. A squash player for 30+ years, I herniated a disc at L4-L5 in 2016, while playing a match, and after a year of intermittent pain, and multiple epidural shots, my doctor, a spinal surgeon, offered a silver bullet. In his words, "If you want to go back to practice the sport you love, you should consider undergoing spinal surgery, most likely a fusion in L4-L5". In retrospect I wish I had researched the procedure much more thoroughly.
It did not end well. I was left with a lot of pain and stiffness in my lower back. The fusion did not heal (the cage was loose), which led to a second (repair) surgery by a different surgeon at a different hospital. And immediately following the first surgery, I developed neuropathy in my legs and feet, of which I have not recovered.
I deal with it. I walk a lot. I swim. I work out for flexibility. I even visit a squash court sporadically. But the pain is always there. 24 x7. It never stops.
There was no silver bullet, just an unfulfilled promise, probably driven by the surgeon’s standard practice. And, in all likelihood, because the procedure is good business, as the article suggests.
I just hope that Tiger Wood's surgery does not trigger an avalanche of spinal fusion procedures. I praise the author for making this matter public. “If you are in a good surgeon’s office, fusion is the last thing you will be offered”. That's how the article ends. I could not agree more.
18
@EJML
I'm sorry about your experience. I'm a fellow squash player with manageable back pain and feel for you. In my small squash community we've lost quite a few older players to back issues- they love the game but decided the repercussions are simply too much. Keep moving and stretching.
4
At the risk of sounding like a whacko, I am going to post this anyway - because if it helps even one person I don't care how crazy this sounds. 10 years ago I developed excruciating sciatica afters many years of small traumas to my back. After a year of physical therapy and specialized exercises, and trying every conservative remedy, I had a dorsal hemilaminectomy at L4-L5 - probably the tiniest, least invasive back surgery available. Didn't help - pain was even worse than before - so much so that I demanded another MRI of my back just to make sure the surgeon had done surgery at the correct joint. Then, for other reasons, I eliminated soda from my diet. Seemed to help. But then randomly the sciatic pain would come roaring back. Until I slowly figured out that carbonated beverages of ANY sort would set off my sciatica. I didn't believe it at first - I'd binge on low-calorie carbonated flavored water, thinking that was better for my diet than soda. Calorie-wise it was better - but boy did it set off the sciatic pain. I now drink NO carbonated beverages and my sciatic pain is reduced 95% - to the point where some days I don't even think about it. I am a medical professional and I can honestly say this makes NO SENSE from a physiologic standpoint and I cannot explain it. But it works for me.
25
I am Doctor of Osteopathy, D.O. boarded in Osteopathic Manual Medicine. One of the most common complaints I treat is back pain. I would say almost all of my patients experience outcomes far better than a 25% improvement in pain levels sited in the article. What I do is non-invasive. No one died last year (or in any year), became addicted or even had lasting side effects as a result of osteopathic manual medicine. Many people I have treated for back pain have had good enough results as to be able to completely stop their opioid, NSAID or other analgesic medications. I always invite patients to try osteopathy as a less invasive form of therapy first, before getting injections and surgeries. I also give patients about four simple stretches they can do in a chair seated at home a couple of times daily that takes about 5 minutes. I see much better outcomes with osteopathic treatment, stretching and PT done together. As part of my residency training as physician I spent three months in orthopedic surgery. One surgeon I worked under, with a specialty in spinal surgeries would openly tell patients of a study conducted by orthopedic surgeons themselves showing at least 40% of people who got spinal fusion surgeries would need surgery in the spinal segment above or below the fusion within 10 years. Physicians, including orthopedic surgeons, and the public need to know there are lesser invasive treatments with better clinical outcomes.
15
I had 3 surgeons recommend a foraminotomy when I got an opinion from a surgeon at Mayo Clinic. He told me that foraminotomy does not work; only fusion could help my problem, but that fusion has a poor success rate and should only be considered as a last resort. 12 years after the onset of symptoms due to a degenerated L5-S1, my pain is substantially reduced, although I still have leg numbness and foot pain. I swim every day and go to the gym at least one a week, and clearly that has had major benefits.
4
Not all back problems are the same. I had "spondylolisthesis, in which vertebrae slip out of place". I have had 2 back surgeries, but after the first the doctor did not put me on a strict life regimen. So I went back to heavy lifting, riding horses, carrying water buckets in the stable, riding a tractor on rough ground, and I broke the fusion. The pain was so unbearable, I was ready to take the gas pipe. My second fusion surgery (different doctor) was 6 years ago.
The pain is gone, and my life is changed. I now hire things done on this little retirement farm. I have a 20lb lift limit. Doc said I could ride horses again...I just could not fall off. Riding a speedy zero turn mower is the worst thing you can do because it hammers your spine. I never pick up a bale of hay or a bag of horse feed, or a heavy suitcase, or a case of wine. I have 7 discs fused. I walk funny, but I can walk. I do not need a cane anymore, and I can stand for hours. Fusion surgery is certainly not for everyone, but it saved my life. Thanks Doc!
6
i had a herniated disk L 4 and L 5. Finally had the Lower Endoscopic Disk surgery in 2005 in California. It was a painful recovery but with physical therapy and exercises and daily swimming i am functional. Rarely have much pain but use an exercise ball and tons of counterpain salve. Use a hollow pillow when driving or sitting on hard chairs. everyone is different. i can't lift more than a pound or so but one learns comping mechanisms. i climb mountains in Laos and China in the tea business. Walk a lot too. Stairs can be a problem if no hand rail and restaurant chairs must have a back not a stool. i have considered another surgery but at age 71 am reluctant to take the risks. Physical therapy is very good and a lot of exercises can be done at home. i also have flat feet and my podiatrist gave me special orthotics inserts for my Nike only shoes. That corrects posture and relates to the back. Some foot massages also are healthy treatment since its all related.
5
Tiger Woods has enough money to pay for the very best state of the art treatment. He also has an iron will far above most of us ordinary mortals. For the moment he has defied very long odds and is enjoying an astonishing success. It probably will not last, nothing does, but I can only applaud and thrill at his story. No matter what technical advances the medical profession may make, the mystery of the human mind, body and spirit will never be solved.
6
@Chuck Burton
I'd love to see what his PT schedule looked like for the year after surgery. Having the time and money for intensive long term rehab would help many people who suffer with back pain, I believe, and I'm one of them. Kudos to him though, this is a tremendous accomplishment.
8
After three years of suffering, my back doctor told me that 1/3 of patients see improvement, 1/3 no change, and 1/3 get worse after surgery. I saw a highly trained acupuncturist and saw tremendous improvement the first month and six months later NO pain. Swinging a golf club or baseball bat are two of the worst things you can do to your spine.
7
I had 5 back surgeries. 3 withing 4 days as things went horribly wrong .
The key to manage back pain is daily exercise. To strengthen my back, I walk every day 40 min with a 10 Lb weight in each hand (I worked up , starting with lesser weights).
I do daily flex exercises. I recommend Robin McKenzie's Treat Your Own Back.
7
@John I agree with you. The McKenzie exercises have worked best for me too.
2
The complicating problem is that the opioids frequently prescribed for pain reduction produce hyperalgesia - worsening pain with continued use. The patient is then prescribed more opioids, and what results is an addicted patient, unwilling to give up narcotics and in even more pain than before the surgery.
1
Do Pilates everyday. Pilates is the best way to create the most mobility and functionality for sports and daily life.
Find a Pilates studio in the area where you live and you will be on your way to a better, more functioning life.
6
I had lower back pain for years and physical therapy and strengthening exercises helped somewhat. But what helped the most was a hernia operation. When your core is weak from a hernia, you can't exercise your way out of it. The support just isn't there, and never will be. After fixing this on both sides with the standard mesh treatment I have improved dramatically. I can still get twinges but they don't erupt into weeks of pain. Many people have undiagnosed inguinal hernias that affect their core strength. Its quite common.
2
I had a hernia repair but it didn't cure my back issues.
Everyone I’ve ever met who has had surgery on their backs & did spinal fusion has ended up having multiple surgeries on the discs above & below. My Mother-in-law, after 5 such surgeries ended up in a wheelchair for the rest of her life & still struggled with back pain.
Unfortunately, unlike the two ethical doctors mentioned in this article, there are way too many surgeons out there who can’t resist the huge sums of money, usually paid out by Medicare, that they receive from doing these surgeries.
One middle aged woman I know went to a doctor for lower back pain and he wanted to schedule her for spinal surgery before he’d even done X-rays! Thankfully she declined and went to a chiropractor instead. After three visits her back pain was gone.
3
When I was a teen, I was playing baseball, went down for a shoestring catch and came up throwing to try and get the runner tagging up from third. Once I stood up straight from the throw, I felt a twinge in my back. My pain just grew from that point on. My doctor would always just recommend do I do physical therapy. By the time I was 38, my left leg and my boot feet were numb. I got an MRI and I was told that I had to ruptured disks, and that the viscous gel was oozing down my nerve bundle and causing all my problems. I had the surgery and had my spine fused at L4 and L5, and after rehab for 8 weeks, I felt great. By my 50's the pain had returned, and now I have pain from my lower back down. No matter how active I am, the pain is always there. I have tried acupuncture and Chiropractor, and those were both a waste of time and money. It seems I am doomed with this pain for the rest of my life.
4
Very informative article of the reality of outcomes in back surgery. But, I have one request...if you suggest “dry needling”, please also mention acupuncture. Acupuncturists can treat systemic symptoms related to the pain, plus needle “where it hurts”. Acupuncture license requires years of schooling and clinical experience. Dry-needling is a certification seminar presented over 3 days.
6
if you have enough money to buy absolutely almost every ticket then its not a lottery or it’s one that is rigged. we should all have Tiger Woods’ “luck”....
3
According to our social standards, Woods has earned his money. What is the purpose of a bitter attack against his right to spend it as he wishes?
3
"it may be risky but he also might get a few more years out of his playing career, which could be worth millions of dollars." Is earning millions of dollars the measure to use for having a risky procedure? As a small fractional millionaire, should I not risk the same procedure to alleviate the excruciating pain I have experienced 24/7/365 for going on 6 years? I have four disks in a row affected as a result of life saving surgery that salvage my spinal cord from further damage by an infection that has left me slightly paralyzed, though painfully mobile, and in pain from my lower back, throughout my legs and to the tips of my toes.
Irony for me is that physical therapy that strengthens my core and back muscles, as my doctors recommend, only make muscle spasm that much stronger deforming my spine and increasing the already high pain making it even worse - rolling on the ground in agony crippling, in fact. Until the spasm slowly goes away over a week.
The prognosis is for pain to continue to get worse for the rest of my life. Fusion will not do anything - they all say - maybe a back fission will! Just blow it apart - that'll take care of the pain ... permanently.
3
When I was 28 years old I ruptured my L5/S1 disk, resulting in extreme sciatica pain where I could hardly sit or walk. I discovered that I had a congenital problem where some of my vertebrae didn't form completely and this put too much stress on the disk, resulting in the rupture.
My surgeon performed a laminectomy and as soon as I was out of surgery my pain was gone, though I had numbness in my foot which has lasted to this day. At the time, my surgeon said there's a possibility it could re-rupture and that I might need a fusion eventually. I've always been an active person athletically, so I accepted the risk. Sure enough, when I was 30 it re-ruptured and I experienced the same issues, and so I had the disk fused and again it immediately removed all my pain.
After the fusion, the doctor mentioned that the inherent rigidity of the fusion would put pressure on the upper disks, so its possible I could have more problems in the future. Well, I was good for 18 years before my L4/L5 disk ruptured, so had a laminectomy to fix it. Luckily, it took care of my pain and I've been fine ever since,
For me the key to a successful recovery has been to continually exercise. Even today at 61, I play tennis, walk a lot, ride my bike and workout in the gym regularly. And for those interested, check out the book, "The Back Mechanic", by a group of researchers at the University of Toronto who've been helping people to manage back pain for 30+ years. Their exercises are a lifesaver.
6
Why do so many people get relief from pain when the disk issue remains? Why do so many people have disk issues without having pain, while others experience pain from the same disk issues? Why is there such a wide variance in success of the surgeries? Because the disk is not to blame.
Dr. John Sarno, who was a top rehabilitative medicine doctor at NYU for many years, noticed these contradictions. Read his books, starting with Healing Back Pain. After 7+ years of horrible back pain and sciatica, countless doctors, physical therapists, chiropractors, acupuntcures, and finally a surgery from a top surgeon that only provided temporary relief, only the theory of healing outlined by Dr. Sarno in his $10 books has given me complete, last relief. When my back issues first started, I was told about Dr. Sarno and dismissed him outright, because it seems so outlandish. But it worked for me and thousands others.
Skip the surgery, and listen to what your body is trying to tell you.
16
@Frank Reynolds I gave this book to a friend I work with over 15 years ago when he told me he was having excruciating, ongoing back pain. The pain went away and has not returned to this day.
2
@Frank Reynolds
If you have a physical problem caused by an injury or deterioration of the bone, Samo’s therapy is not the answer. The doctor basically says the pain is in your mind. I tried his approach, which is to go about regular activities with the theory that the pain will subside or vanish once you see that it’s mind driven. It didn’t work.
2
@Frank Reynolds
It's unfortunate that most people are not open to Dr. Sarno's theory. His information is the answer to eliminating most back pain as well as some other health issues. If you are suffering from back pain please read his books...you have nothing to loose but your pain!!!!
As a nurse I would never choose spinal surgery until I had exhausted every other modality I could find. Physical therapy is expanding its modalities in strengthening the back and reducing pain. People don't follow through with their treatment though. Unfortunately too many people would rather believe in a quick fix even if the results are dubious.
20
Finally, an article that tells a truer story of back surgery. In 2006 when I ruptured disks in my low back, my doctor told me that if I could stand the pain, I could forgo surgery and have a similar outcome to laminectomy. Trouble was, I couldn’t stand the pain. It was like someone had boiled radiator fluid and poured it down my leg. Oh, and I kept falling over.
There was another problem with the doctor’s description of outcomes: I didn’t have sufficient information to understand fully what he was saying. He didn’t tell me that I would be in pain for the rest of my life, with or without surgery.
So I had one surgery. Then, six months later, I had another surgery. Then a year later, I had a third, which included fusion. These were followed by more procedures. Maybe if I had a sympathectomy (where doctors burn out the sympathetic nerve system to the affected area) that would help. It didn’t, in fact it made it worse. Permanently.
Acupuncture, massage, physical therapy, pool PT, you name it, I tried it. When I started talking to my pain doctor about assisted suicide, we tried one last thing. They sent me to an interventional pain doctor (all these specialties I didn’t know existed) who determined that perhaps a spinal stimulator might help. Thankfully it helped some. I still live with pain, and have grieved the loss of being an athlete.
Back pain is difficult. There is no getting away from it. Surgery is not always the answer.
10
@Barbara N. Bailey Hang in there, been there, done that. Some days are better, try to stay positive. Pain does things to your brain where it affects how you think in a negative way, finding ANY way to counter that is key.
3
5 years ago at age 47 I had L4 - L5 spinal fusion and disk replacement at the Hospital for Special Surgery. The pain takes over your life. I used to dread even sneezing. I couldn't stand for more than 3 or 4 minutes. I am cured. I am so grateful to my surgeon.
11
55 years ago my father in his forties had spinal fusion surgery. He had two disks removed, three fused. Prior to the operation he had been in constant pain for well over a decade. He constantly wore a back brace. The problem was aggravated by his work as a court reporter having to sit for long periods of time. The surgery at the time took over six hours. When he recovered he threw away the brace and spent the rest of his life free of back pain. He lived until he was 85.
6
As a pain management doctor, I am glad this appeared.
Unfortunately, I usually see most back pain patients after they have had surgery and the pain hasn't resolved. They are usually promised by the surgeons that surgery is the only answer for their pain and I can't think of the last time a patient told me that anyone before me had told him that MRI findings are, with rare exceptions when there are multiple symptoms, worthless for diagnosing a cause for back pain. In fact, it is closer to 2/3 of people without back pain who have at least one bad disk on an MRI and 40% who have two or more bad disks.
Even when there is an actual herniation of a disk, a relatively rare cause of back pain, conservative non-surgical treatment of the pain is as successful as surgery.
Unfortunately, while Woods may have had major incentives to keep getting surgeries even after so many failures, many people who don't have those same incentives continue to get repeat surgeries because surgeons keep promising them a cure.
And people wonder why we spend so much on healthcare. In most other countries with national healthcare systems, the surgeries won't be paid for unless there is a clear indication that they are needed.
20
@Steve For many people, back surgery is the only way not to spend about two years debilitated while "pain management" specialists experiment with various therapies, often including opioids. This is a very bad example of how to save money on health care. The "pain management" costs can add up to just as much as surgery over years, after which the patient might need an operation anyway.
3
@Mary k
First of all, most back painpatients who undergo surgery aren't offered any treatments beyond medications and even then most receive only a few of the potentially beneficial ones.
There's one very big difference between those other therapies which have few adverse effects and those that occur can be easily managed, and surgery where there is no way to reverse what you end up with.
No one's saying there aren't patients who may benefit from surgery but as we don't have any way yet to predict who they are in most cases shouldn't we give conservative treatments a try before going on to surgery? And those conservative treatments also happen to be a lot less expensive than surgery.
2
@Steve I've been doing conventional, conservative treatments for 10 years, along with acupuncture and massage. Worked on my core, which only seemed to make matters worse. Had the decompression/laminotomy in 2016. Iatrogenic problem (surgeon took out too much bone) which has caused a fast moving scoliosis and spondylolisthesis throughout my lumbar spine. My scoliosis surgeon has said to wait until I can't stand the pain anymore. Breast cancer has done a number on me, but I won't take the aromatase inhibitors prescribed for the cancer because the side effects all have to do with bone loss, joint pain, arthritis, etc. Already got that stuff. Quality of life is important to me, so at 61 I am going to do the multi-level fusion with posterior instrumentation and hope for the best.
10 years of conservative treatments and acupuncture have cost me thousands of dollars out of pocket, thousands of dollars to my insurance company, and thousands of dollars to my disability insurance company which can't wait to get me off its rolls. And I lost my career because I couldn't sit due to excruciating pain. It's all expensive.
2
Neurosurgeon here. Fusion is dramatically overused - especially in the obese.
When your inactive lifestyle leads to your spinal degeneration, it is unreasonable to think you have the physical determination to rehab effectively.
Tiger woods is a word class athlete, he is a professional. He had a focal pathology at a single spinal segment, for which he underwent anterior fusion surgery. His excellent result is more predictable than it is miraculous.
I’m a little worried that the chronically sedentary/unhealthy with back pain and no neurologic deficit will see tiger’s successful outcome as an advertisement for a quick fix.
59
I am surprised that no one talks about Artifificial Disc Replacement as an alternative to fusion. It is not for every condition and it is by no means a perfect surgery either but studies are coming out that it prevents adjacent segment breakdown which is probably the biggest drawback to a fusion. Many surgeons don't even know how to do it and insurance companies are just starting to cover it over the last couple years. Tiger Woods latest doctor actually specializes in this procedure.
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The most important information in this article is this:
- About half of middle aged people with no back pain have degenerated disks.
- Disabling lower back pain from degenerated disks often improves on its own, eventually. It’s not clear why because the disk is still degenerated.
I learned this information years ago only after seeking it out. I certainly did not get it from doctors who were content to send me for an MRI, despite it being named in numerous studies as one of the most overprescribed procedures in medicine and not necessary for my particular condition. It was actually my physical therapist who told me the truth: The medical profession really has not figured out the back yet. I told him I had seen my MRI with two disks in poor condition. He told me there was little correlation between disk problems and back pain. I didn't believe him until I looked up the medical study he cited. My conclusions from the whole experience were the following:
- Most back pain is idiopathic and unrelated to disk condition.
- The best solution for back pain is to experiment to find what helps and then stick with it (in my case, walking helps).
- Trust physical therapists over doctors.
- Read medical studies because, again, you can't trust doctors.
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@Locho
There certainly is a direct relationship between deteriorated discs and pain. I've had discs blow out and a 3 level fusion and it stopped the pain.
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@Anita Larson
"Most back pain is idiopathic and unrelated to disk condition."
As I wrote above, "most" not all.
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Instead of calling the success of Woods' back surgery "a lottery win," doctors should seek to understand why he got good results when so many others didn't. Better doctor? Better rehab? Better muscle tone before?
"It's just random "(a lottery win) is not good science or good medicine.
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I am a retired podiatrist and had an entire practiced based on biomechanical management of gait (walk) style as a treatment method. In 1999, I published the outcomes of 32 patients considered at medical endpoint for chronic lower back pain. We used custom foot orthotics and lower extremity manipulation (mostly ankles) and followed these patients for over one year (13.9 months average). We showed an 84% cure rate without recurrence during this time period.
What was most interesting was that this approach showed that by using foot orthotics which increased stride length, it secondarily improved hip extension. This had the effect of making the act of swing phase far easier. It was this change in limb position which then eased the strain on the hip flexors muscles, which originate directly from the lower lumbar vertebra and disks.
If you have a headache, and hit yourself in the head with a hammer, the pain won't go away until you loose the hammer. Since average humans take 8,000-10,000 steps/side/day, this is very analogous. Don't miss having your gait checked as part of a complete back exam.
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@Howard
Could you please supply a link to your study? I'd like to read it. Also, any advice on where to get an adequate gait study? Is that something any podiatrist can do?
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@Howard
I don't care what treatment you use, no one has an 84% cure rate for low back pain.
And the back is a very complicated structure with many things in it that might cause pain. To claim that all or even most cases of back pain can be traced to a problem that can be solved withorthotics is ludicrous.
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@Steve
This was published it in a reviewed journal, and I can assure you that the outcomes were as I described. Patients filled out a pain questionnaire before the study started, at 3 months post and then over one year. The symptoms resolved long term and this was a major change in approach to CLBP.
The point here is that stress to the LS spine is related to a simple daily activity which was overlooked in almost all research. And, most importantly, it was not impact shock during walking, but rather how swing phase motion occurred. The hip flexors (iliospoas) is a major factor in back pain symptoms, and while stretching it is common in physical therapy, relieving the gait related stress is not. This is such a simple approach that I am not sure why it has not been used more often.
I understand your skepticism, but this is a major cause of these symptoms and has been overlooked by surgeons who simply look directly at the lower back, and not how daily stress is applied to it.
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I’m glad this article discusses physical therapy and flexibility work to truly address back pain. I wish it was a less shallow dive. I’d recommend another story focusing on different body work modalities that have shown results.
Having had two surgeries: both double laminectomies at L4/L5, I can attest to the need for additional work beyond physical therapy. In my present recovery (since 2012), I hav made use of yoga, chiropractic, acupuncture, Pilates and ELDOA. I found that acupuncture was most helpful immediately after surgery (for regaining sensational and muscle control). Chiropractic has been worthwhile only for acute pain with loss of mobility. Pilates was useful in learning to transfer muscle strain to my abdominals and for some basic, occupational therapy when dealing with dishwashers, stackable Landry machines, and lifting. What has proven most useful to me (read: I have not “thrown my back out” for 3 years) has been ELDOA. This method focuses on decoapting spinal vertebrae through my fasciae stretch and static poses. It has helped me to counteract regular stress patterns I hold in my body. While I have tried yoga, I find that the focus is on full-body strength and stamina, not reparative muscle elongation and motility.
Given how many people are impacted by chronic lower back, mid back, and neck pain, it would be helpful to produce a series of articles about different, non-surgical therapies and outcomes.
Thank you for your interest in this issue.
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@Lonny Stern Very interesting! I am going to learn a bit more about ELDOA. After two back surgeries (and permanent nerve damage / numbness down the length of my leg from the first one), I'm always looking for alternatives to ANY more surgeries. I no longer trust them to fix the problem and I will never again see them as a "cure." I find yoga and Pilates difficult because of my numb leg and foot but the ab work is helpful. Swimming also helps as well when I'm sore. Really I'm at the point where I will do anything to avoid a future surgery and so I admire your all-hands-on-deck approach.
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The SPORT trial, the largest of its kind, shows that fusion surgery for many is not better than conservative therapy - once you get out to several years after the surgery.
The issues with adjacent segment disease - breakdown of areas of the spine around the fusion are real.
This type of surgery has a role in patients with neurological complications of spine disease - such as numbness and weakness of the legs/arms. However, patients with pain as the only symptom often do better or the same with more conservative approaches.
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Conservative measures should be exhausted before one succumbs opts for surgery. Operating on a patient that is morbidly obese, physically out of shape is futile. Physical therapy ,weight loss and life style changes and serious motivation should be the first options. Most surgeons will not operate unless the patient
has demonstrated a commitment to do the arduous work it takes to recover.
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@bernard oliver
How does an obese person exercise when they have a blown disc? The excruciating pain often prevents movement.
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I was able to serve a tennis ball 120 mph a year after L4-L5 laminectomy when I was 23; I was/am 5'9", 170 pounds. I had ruptured my disc in ICTCs the prior year. Sciatica that would not be alleviated for 6 months prompted the surgery; I still have no reflex arc in my right ankle.
I rehabbed profusely--1hour twice a day in a pool. When I saw my surgeon 6 months after surgery he remarked how my lats had grown like wings.
Taking rehab seriously is the key.
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Eighteen months ago, I had a complex, nine hour surgery on three levels of my spine (a 360 procedure where they go in through the front, back and side). It changed my life. Fusions, rods and cages stabilized a spine with a 27 curve, arthritis, and spondylitis. Before the operation, I could not stand for more than 15 minutes and a walking any distance was out of the question.
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@Christine Barabasz 18 months ago? I want to know how you are doing in five years..No surgeon ever follows results for that long -it is a huge joke, like only looking at global temperature rise after 1998..
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My caveat here is that I am a spine surgeon. I would argue that lumbar fusion for severe degenerative disc disorders in the right patient is one of the most satisfying surgeries I can offer. I wrote a paper back in 2013 delineating the success rate (satisfaction after one year) was at that time 84%. It is now about 90-92% in my practice. The wrong patient, the wrong surgery or expectations that are too high (everyone can't expect Tiger's success) will increase the failure rate.
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@Donald S. Corenman, M.D., D.C.
Unfortunately for many back surgeons, the definition of the "right patient" for surgery is one who has insurance that will pay for the surgery.
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@Donald S. Corenman, M.D., D.C. you define success as one year? Are you kidding me? I got L4L5 spinal fusion surgery after two years of trying everything else, and one of the questions I had for the surgeon was what happens after five years, ten years...He yelled at me, typical ofo most surgeons I have found, "No-one follows this for that long!" He had been in the business for twenty years.
How hard would it be to track your own patients - one year is totally not acceptable. I am five years our from fusion surgery,and almost back at the pain level I was at before the surgery, after two years of no pain..One year? What a joke. It is almost irrelevant! Much less worthy of using as data for a self-serving assessment.
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@Donald S. Corenman, M.D., D.C. I am now five years out from double fusion spinal surgery, L4-L5, for spondilolisthesis (sp), and some scoliosis, and before I got the surgery I tried to ask the surgeon what happens in five years, ten years, and he, ( typically, for surgeons I have known), lost his temper at me and shouted "no-one follows this for that long!!" Nice..So now, five years out, i am almost back to where i was before the surgery for pain..So your 'conclusive' one year study is a total joke. What, am I supposed to die or retire after one year?? Why not keep a record of all your patients and track all of them, over the years? How hard would that be? My surgeon was in the biz for 20 years, gut he obviouisly felt it was ridiculous to follow his patients past a few months to a year..
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I had a highly complex fusion (L4-L5-S1) when I was 30; I had had escalating symptoms (unbearable pain, sciatica) for 10 years at that point, and had visited innumerable doctors, physical therapists, etc., desperate for help. For the most part, they either denied my symptoms or said I'd just have to live like that (I am not a professional athlete, and not a man - in the 80s especially, this meant my pain could easily be ignored). Then I found an exceptional surgeon - exceptional not just because his surgical skills were above average, but because he took an informed, intelligent, compassionate approach to evaluating my case. He wouldn't do a fusion if he didn't have a high degree of confidence that it would help me. After 6.5 hours of surgery and about 9 months of recovery, I've had close to 30 years of excellent health. I believe he saved my life.
A few years ago I had a whole new set of symptoms, resulting in a diagnosis of severe spinal stenosis: my spinal cord was being crushed. I had another fusion (C5-C6-C7) with a different surgeon, only after THAT surgeon had firmly established that this surgery was likely to be helpful. Again, full recovery, no pain, no numbness, no more stenosis.
Bottom line: for surgery-happy surgeons success rates will be low. For surgeons willing to take the time and evaluate an individual patient to determine likelihood of success, I believe success rates are likely high.
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I am a spine surgeon. This article is excellent. I particularly liked the part where they discuss passive treatments that are commonly employed by physical therapists (ultrasound, TENS units, dry needling).
Cognitive Behavioural Therapy (changing the way you think about your pain) and improving biomechanics through resistance training and flexibility are the keys.
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@Ben n
You're onto something with support for physical therapy and behavioral change for pain of a certain nature.
However, some back pain, such as from a nerve-root-compressing cyst in degenerated facets in the lumbar region, will not go away with physical and cognitive therapy. The cyst has to be removed, either with laminectomy or fusion.
The key is discerning the nature and cause of the pain.
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@Ben n I am a physical therapist and am frustrated at the overgeneralized, misinformed commentary about my profession. No PT worth their salt gives a patient "passive modalities" anymore. It would be uncommon and ridiculous to assert this.
Just as with physicians our practice is evidenced based, and we all use the same research from peer reviewed studies. PT's specialize in movement dysfunction and use active, therapeutic interventions to treat impairments. I don't know anyone who uses ultrasound and TENS electrical stimulation is used to facilitate a patient more comfortably tolerating an active task – not as a treatment by itself.
Rehabilitation is a tough journey, it's more sophisticated than portrayed in this article. Strengthening is important but if that was the basis of physical therapy then people could just go to the gym and be fine.
As regards back pain/surgery there are neuromuscular re-education issues from compensatory movement patterns; coordination, motor control and activation issues as well as neuro-dynamic considerations and gait training. Specific skilled strengthening progressions are used to address force imbalances and patients receive comprehensive education regarding their condition, pain science, fear avoidance behaviors, self-management techniques, ergonomics and finally any specific return to sport requirements.
When guided with expertise - has been proven over and over again to be highly effective conservative treatment.
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@DC
yes, there are cases of back pain where there is an identifiable cause such as a cyst or a tumor or infection but studies have shown that in over 85% of cases of back pain we have no idea of what is causing the pain.
And in virtually every one of those cases where there is an identifiable cause, there are multiple other symptoms that are beyond the pain red flags that there is such a cause.
Unfortunately many physicians still remain either unaware of these red flags or, in the case of many surgeons, have a strong financial incentive to ignore their relevance.
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