Diagnosis

How and When to Get a Second Opinion Before Surgery

spine-health — Wed, 15 Aug 2007 16:39:46 -0700

August 15, 2007
by: Peter

It is often said that no one should have spine surgery unless they receive a second opinion from another surgeon. On the surface, this would sound like good old common sense, as two opinions are better than one. However, there is a trap in this line of thinking. When a patient sees a physician for a second opinion, this next opinion has a tendency to always sound smarter than the first opinion. This is a well-recognized phenomenon, but in reality the second opinion may not be the best one.

When should you get another opinion?

Certainly if you are not comfortable with the first physician, then seeing another surgeon for an opinion is a good idea.
If a surgeon cannot answer questions about the rationale for a proposed procedure or is vague on the surgical plan, another opinion is a good idea.
If you suspect that the initial referrals was made on the basis of economic interests rather than who is best suited for your surgery, go for another opinion. (Referring physicians favor local surgeons who will do the surgery in a local facility, especially if they are in a multispeciality clinic. This is not saying that these physicians are not capable but that there is a possibility that the first referral one receives may not be the best.)
Another time it is good to get a second opinion is if the initial [url:165,type=|term|,content=|back surgery|] did not work and another surgery is being proposed. This is especially true if it involves fusing further segments of the spine. Often, if the initial fusion surgery does not work, further surgery will not be helpful. Only in very specific circumstances (i.e. pseudoathrosis) is further surgery likely to be beneficial.
There are times when a surgeon will ask a patient to get a confirmatory opinion prior to proceeding with surgery. In these cases it is best to let the treating surgeon pick the second opinion as they are best able to determine whose opinion they would value.

Otherwise, picking a surgeon for a second opinion is often difficult. As previously stated, the goal is to get an opinion from a respected, experienced and ethical surgeon. While it is not perfect, word of mouth is probably still the best measure as to who could be helpful in the second opinion process. This is, however, still a relatively arbitrary process.

The best thing for a patient seeking another opinion is to keep an open mind. You need to be as judgmental about the second opinion as for the first, and need to grill the second physician even further than the first. Beware of surgeons toting unrealistic expectations or who are overly dependent on “cutting edge” technologies. Focus on their experience with your specific type of back surgery and what the surgeon's past outcomes with that surgery are. What are the alternatives to a proposed procedure, and what is the expected natural history of the patients condition if they do not have the procedure? What are the risks and possible complications of the procedure, and if it doesn’t work, what would be the subsequent plan? Read all [url:6634,type=|node|,content=|38 Questions to Ask Your Surgeon Before Having Surgery|].

Remember, the worst thing to do is assume the second opinion is automatically going to be better than the first. Keeping an open mind will prevent you from falling into this trap. And if you’re still not sure, ...get a third opinion.

Posted by: Peter Ullrich, MD

Get Your Back Pain Diagnosis from a Physiatrist

Wed, 11 Jul 2007 12:33:21 -0700

July 11, 2007
by: Stephanie

Whenever someone with bad back pain asks me where to get help, I say I would start with a diagnosis from a [url:1720,type=|node|, content=|physiatrist|] who specializes in back pain. Here is why:

Most physiatrists can provide you with the broadest array of treatments for [url:140,type=|term|,content=|back pain|]:

Spinal injections (for diagnostic and therapeutic purposes)
Prescription pain medications and anti-inflammatories
Heat and ice and other pain modalities
Physical therapy
Education on ergonomics, posture, etc.

I like the general orientation of the physiatry, which is to provide enough pain relief to enable patients to make progress with rehabilitation – the best long term solution. (I’m not saying that practitioners in other specialties don’t have this focus, many do, but my impression is that physiatrists are most likely to have this focus.)
Most physiatrists have a strong surgical referral network. So if you really do need surgery, they would be able to refer you to a surgeon who they know has done a good job for other patients.
Many are part of an integrated clinic or network of clinicians to provide coordinated care, e.g. chiropractors, [url:170,type=|term|,content=|pain management|] specialists, physical therapists, psychologists who specialize in pain, etc. For complex cases, this is often the best way to go.

Again, let me repeat, I realize that clinicians in many [url:1969,type=|node|,content=|specialties|] have many of the above qualities, and I am not saying that every physiatrist is good at treating back pain. I am highlighting this specialty’s training and approach to treating back pain because, in general, this seems to be a medical specialty that many consumers don’t know about, and I would like those seeking back pain relief to know about this option.

Posted by: Stephanie

More reading:

[url:1720,type=|node|]

How to Help your Surgeon Help You

Tue, 01 May 2007 19:12:52 -0700

May 1, 2007
by: Sylvia Marten

Anyone who has experienced [url:137,type=|term|,content=|chronic low back pain|] knows how frustrating it can be to find a doctor to help. From a surgeon's perspective, I often see patients who have seen multiple other doctors and physical therapists and have not had relief of their pain. (After all, if non-surgical treatment was working they wouldn't be coming to me to get a surgical opinion in the first place.)

If you've had your back pain for a long time, you already know that finding the cause of the pain and an effective treatment is quite complicated. Treating chronic low back pain is almost like detective work, and the better the communication is between the patient and the physician, the better the expected outcome. Apart from basic courtesies such as arriving to your appointment on time with all your paperwork ready, there are several important things that you can do to assist in your own care.

Treating chronic low back pain is almost like detective work, and the better the communication is between the patient and the physician, the better the expected outcome.

Document the treatments you've already tried
Knowing ahead of time what you have tried and whether it worked (even if it worked for only a short time) is helpful. The more information you can give pertaining to your prior care, the less time will need to be spent [url:1872,type=|node|,content=|re-exploring these treatments|]. Being specific about the treatments is also very important.

Just saying you have tried physical therapy is meaningless. What the physician will want to know is what was tried in [url:1183,type=|node|,content=|physical therapy|] and for how long. Are you still continuing with an excercise program? Did the therapy just consist of ultrasound and hotpacks with no active excercise? Were you instructed in core stabilization exercises?

Similarly, if you have tried [url:1915,type=|node|,content=|pain medications|], the physician will want to know the specifics on which medications have been tried, at what dosage and for how long. Did they help with the pain or help increase daily functioning? The same is true for any injection. What kind of injection was it? Did it help and if so how much and for how long.

Having all of this written out prior to the appointment will help the physician be able to quickly understand and assess your situation, and it'll make sure you don't forget anything.

Bring any prior imaging studies
Besides the history and physical exam, the next most important piece of information to a surgeon is the [url:729,type=|node|,content=|imaging studies|]. The actual imaging studies are what will be needed. Reports on imaging studies (vs. the image itself) are pretty much meaningless as there is no standardized terminology for reporting on imaging study findings. Old studies can also be useful to see if there are any progressive changes.

Ask the physician in person for any paperwork
At the end of an interview, you should not be afraid to request any needs you have such as medication refills or return-to-work paperwork. It is far easier to close out all these practical problems of chronic low back pain while you have face to face time with a physician rather than ask their staff for these items on their way out of the office or calling back later.

Keep the peace
Lastly, while dealing with chronic low back pain is frustrating, and we all know that dealing with the healthcare system can also be frustrating, it never helps to get angry with your surgeon on the first visit. This may sound obvious, but it happens. Some patients lose perspective and take their anger and frustration out on the surgeon, which will not help the patient and may cause the surgeon to ask them to leave.

Remember, especially if this is the first time you are meeting with a surgeon, he or she is not to blame for your pain and may actually be able to provide your best chance for some pain relief.

Have clear expectations of what a spine surgeon can do for you
When you consult with a spine surgeon, what he or she will be mainly looking for is an anatomic lesion (problem) that is both the probable cause of your pain and is amenable to surgery. Basically, [url:1563,type=|node|,content=|spine surgery|] can only decompress a nerve or stabilize a painful motion segment, and these two conditions comprise a surprisingly small percentage of all the causes of chronic low back pain.

In about 80-90% of cases no anatomic lesion can be found as a cause of the patient's pain. This does not mean the patient has no reason for the pain he or she is experiencing; it just means that an anatomic cause of pain is not identifiable and this is not uncommon with back pain. Understandably, this disappoints many patients, as they may feel their pain has not been validated and surgery cannot provide a clear course of action for pain relief.

After the initial consultation, a spine surgeon should be able to tell a patient whether he or she may be a surgical candidate. Most patients conditions will fall into one of three categories.

They may definitely have a surgical lesion
They may have a lesion that is potentially surgical but requires further work up
They may have no identifiable anatomic lesion as a cause of their pain.

The patient is the only one who has the pain, and the only one who knows how it is impacting his or her life. The surgeon should be able to articulate what can technically be done and what kind of postoperative course and outcome a patient can reasonably expect. Armed with the knowledge from the surgeon a patient should be able to make an informed decision. The patient information on this site can help a patient with their decision making process.For those patients who have an anatomic lesion that potentially may be treatable by a surgical procedure, they will want to know the same above information before further workup. If they do not have enough pain to undergo surgery, further workup is not warranted. For instance, if the proposed surgery is a fusion for degenerative disc disease, and a discogram is necessary as a preoperative study to confirm if surgery would help, a patient may choose not to undergo the discogram if they do not wish to consider fusion surgery.

If a surgeon cannot articulate what a patient has and what type of treatment will be potentially advantageous, the patient may want seek yet another opinion. After all, deciding on surgery can be very difficult and if the surgeon cannot help in this process, it is doubtful he or she will be effective in helping one deal with postoperative rehabilitation or treating potential postoperative complications.

Additional resources:

[url:1547,type=|node|,content=|How to select a spine surgeon|]
How to find a good spine surgeon