Three spine surgeons discuss their patient selection process and why this step is one of the most important in spine care.
1. Understand appropriate indications for surgery and non-operative care. The criteria used to select patients for spine surgery will ultimately determine procedure outcomes. "Case selection is everything," says Stephen T. Onesti, MD, partner in Neurological Surgery PC of Long Island in Rockville Centre, N.Y.
There are many causes for spine pain, all of which can lead to multiple diagnoses. Not every patient that visits a spine surgeon is a candidate for surgery.
"The right diagnosis and the right procedure do not always have to be surgical. The important thing is finding the right treatment for your patient," says Jeffrey Carlson, MD, president and managing partner of Orthopaedic and Spine Center in Newport News, Va.
2. Be confident in your diagnosis. The first step to selecting the right patients is through examination and correct diagnosis. "We must evaluate the whole patient," says Dr. Carlson. "We as spine surgeons think everything revolves around the spine, but patients often have other issues as well." For example, patients with back pain as a result of hip issues might seek a spine surgeon's expertise when really they would benefit from a hip specialist.
Before leaping to surgery as the answer, many spine patients benefit from conservative treatment with physical therapy, heat and rest. Patients that suffer from chronic pain may benefit from advancements in pain management, such as spinal cord stimulators. When deciding whether or not to pursue surgery, spine surgeons ultimately rely on their best judgment.
"There is no absolute set of criteria. It is almost a subjective decision and it always has to be made on an individual basis," says Dr. Onesti.
3. Determine patients' comorbidities. Extraneous health conditions, aside from spine issues, can limit the success of surgery. Diabetes, morbid obesity or smoking are all issues that play into how successful a surgery's outcome will be. Surgeons still regularly perform surgery on patients with these comorbidities, but often take extra precautions to achieve the best outcomes possible.
"I am not advocating that you only operate under perfect storm conditions. Even those with morbidity factors can still need surgical intervention," says Andrew Cash, MD, director of the Desert Institute of Spine Care in Las Vegas. Though comorbidities are outside of a spine surgeon's control, these factors play an important role in where a surgery will be performed.
With advances in technology and minimally invasive techniques, many spine cases are moving to the outpatient setting. For many surgeons, patient selection will involve deciding which patients are candidates for the outpatient setting and which patients need to remain in the inpatient setting.
"The most important question is 'Can we do it safely?'" says Dr. Cash. Patient co-morbidities, ASA grading, procedure complexity, patient preference and insurance coverage all play a role in determining whether or not a patient is an outpatient candidate.
4. Take the time to provide patient education. Well-informed patients are more likely to have better outcomes. Education can come in the form of reading material and videos, but the most valuable education comes from face-to-face interaction. "This is just good old fashioned doctoring. Introduce yourself, take the time to listen to them," says Dr. Onesti. This process does not occur over the course of one visit. Patients will need time to absorb the meaning of their diagnosis and prepare questions to ask their surgeon. It often helps if patients bring family members to ask the questions they forget and help them get answers in a logical fashion.
Patients that need spine surgery will inevitably base their assumptions on stories they have heard. "Every time I mention surgery to a patient, one of the first things I hear is 'I have heard so many horror stories about back surgery.' I'm sure this reaction resonates verbatim in all spine surgeons' practices," says Dr. Cash. Education is necessary to combat this fear and prepare patients for the realty of their surgery. "Failed spine surgery goes hand in hand with patient education," says Dr. Carlson. "Everyone has to be on the same page diagnostically and educationally."
5. Manage patient expectations. Though fear is strong element of patient reaction, there is also a tendency to overestimate the outcomes. Spine surgeons have a clear idea of what to expect after the surgery, but what patients think is often entirely different. "Our 'better' may be that you will be able to walk again, while patients may think 'better' is going skiing again," says Dr. Carlson.
Most spine patients have been dealing with pain for a significant length of time before visiting the spine surgeon, and straightforward communication is appreciated. "I don't like to sugar coat it. I want realistic expectations in every prognosis and every treatment," says Dr. Cash. As spine surgeons walk through the process of patient selection, open communication always steers surgeon and patient expectation towards equal footing.
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