Choosing the Best Spine Surgeon for Your Back Pain

Peter Ullrich, MD

Grant Cooper, MD

Spine-health.com expert featured on Back Pain Radio

Dr. Peter Ullrich, MD, a Wisconsin orthopedic spine surgeon and co-founder of Spine-health.com, and Dr. Grant Cooper, MD, host of Back Pain Radio, discuss how to choose the right spine surgeon for your back pain.

Transcript of Back Pain Radio show on How to find the best spine surgeon for your back pain

Getting a referral to a spine surgeon

Dr. Cooper:
There is a wonderful article on www.spine-health.com about how to find and select a spine surgeon and I would like to explore that topic with you now. Suppose you have been going to your primary care doctor or perhaps a physical medicine rehabilitation doctor and you agree with your doctor that it is time to at least consider the prospect of spine surgery, that it is time to talk to your spine surgeon. What is the typical process from that point on for finding the best spine surgeon for your needs?

Dr. Ullrich:
Unfortunately, our processes for that are still fairly archaic. Usually, you are going to get a referral from your physician and you have to trust that the referral is to the best surgeon there is available because there is not any database on who is a good spine surgeon and who is not. That has not been developed yet.

Dr. Cooper:
So if there is no database yet and you are trusting your primary care physician to give you that referral, is that a good thing to trust? How is your primary care doctor making that referral?

Dr. Ullrich:
It depends on the situation. Medicine is a business and a lot of the referrals are based a lot on business tie-ins. Your primary care doctor or a lot of physical medicine rehabilitation doctors do not really have a way of telling who is a good surgeon either. So they are going to refer to the people that are inside their system, either within their hospital system or a multi-specialty clinic. But they do not have a lot of data to go off of either.

Dr. Cooper:
If you are in the position of trusting your primary care doctor or your physical medicine doctor, is it then safe to trust that referral decision?

Dr. Ullrich:
At least initially, but one question you can ask your doctor when you are getting the referral is, “Is this the best person that there is to go to, and would you send your family members to this person?”

Dr. Cooper:
Which is always an excellent question, no matter what the healthcare decision is – would that doctor do that for themselves?

Interviewing a prospective spine surgeon

Dr. Ullrich:
Right. And when you get to the surgeon, there are some good questions you can ask them at the time of the interview.

Dr. Cooper:
What kinds of questions?

Dr. Ullrich:
What their experience is in spine surgery, the number of cases they do, does it make up a large part of their practice or just a small part of their practice and they do a lot of general orthopedic or other types of cases. Another important thing, especially if you are considering a fusion, is fellowship training. Fusion surgery is difficult enough and it seems that people who do fellowships in it have lower complication rates. Paul McAfee out of Baltimore wrote a good article a number of years ago about especially with inter-body fusions a fellowship-trained spine surgeon had four times less complications than a non-fellowship-trained surgeon.

Dr. Cooper:
That is an impressive number. Four times less the complications.

Dr. Ullrich:
And that was for a specific type of surgery. It is at least an important thing to know that the surgeon is interested enough that they have gone on and done additional training in spine surgery or at the very least that it makes up a good part of their practice.

Orthopedic surgeons vs. Neurosurgeons

Dr. Cooper:
Before you even get to the spine surgeon... There are different kinds of spine surgeons – there are orthopedic spine surgeons and there are neurosurgeons who went through a different residency training. Is one more equipped for certain types of spinal surgery than others?

Dr. Ullrich:
In general they both can do spine surgery equally as well and both have had extensive training in spine surgery. An orthopedic surgeon is probably more interested in deformity types of surgery, like scoliosis surgery and large deformities. A neurosurgeon is more capable of doing intramedullary tumors, tumors that are inside the central nervous system. With some specific indications, one is probably better than the other. But for the most part, it has more to do with the training and the level of interest in spine.

Dr. Cooper:
Is the fellowship that they do the same type of fellowship, or are they divided into specialties as well?

Dr. Ullrich:
Normally most neurosurgeons are going to do a neurosurgical spine fellowship and vice versa for orthopedic surgeons.

Dr. Cooper:
So they are actually divided into the different specialties, OK.

Dr. Ullrich:
Yes, but a lot of them are going to the same societies, like the North American Spine Society, which is multidisciplinary, including physical medicine rehabilitation and then both surgical specialties. So the training is getting very similar for both specialties.

Dr. Cooper:
In terms of asking about a fellowship, a problem that you would run into if you were asking, for example, a physical medicine interventional doctor about fellowship training is that if they are out of their residency for 10-15 years, there were not fellowships that long ago and fellowships are a new thing. Is it similar in spine surgery or have the fellowships been around for a long time?

Dr. Ullrich:
If a doctor has been out of for more than 15 or 20 years, they probably have not done a fellowship. But that is where the next questions is – how much of their practice is spine surgery. If in their 15 or 20 years they have been concentrating on spine surgery, a fellowship training would not be needed. But if they are early on, you want to know what their level of interest is and if they have done any additional training.

Comparing techniques for spine fusion surgery

Dr. Cooper:
Is it important to ask them about different techniques that they might use? There is a multitude of ways of approaching even fusion surgery. Is it important to ask the spine surgeon what type of fusion procedure they do?

Dr. Ullrich:
Absolutely. They are a number of surgeons who do all their fusions from posterior. A lot of us prefer doing the majority of the fusions from the anterior, which is a more biologic operation and gives you a better support, or doing a front-back fusion. But if you see a surgeon who does not ever go from the front, he will not offer you a front-back fusion. You will not get offered what they do not do.

Dr. Cooper:
So it is important to do your homework before you even get there so you have some idea of what they are talking to you about when they are talking about the different surgical options.

Dr. Ullrich:
Absolutely. The best thing to do is to, if you can, know your diagnosis ahead of time, go to a website such as www.spine-health.com and at least read about the different surgical treatment options and then come armed with questions.

Dr. Cooper:
But like you said if you find somebody that does just posterior, they are not going to talk to you about anterior because that is not what they do.

Dr. Ullrich:
Right.

Dr. Cooper:
Would it reassure you if they said, “I do only posterior, there are anterior approaches, and these are the reason that I prefer to do it this way”?

Dr. Ullrich:
If they at least have a reason why they go only posterior and they have good results. Another question to ask is what their results are with your type of diagnosis and what the complications rate is.

Success rates after spine fusion surgery

Dr. Cooper:
Can most physicians give that to you? Have they done an audit of themselves or are they going off the top of their heads?

Dr. Ullrich:
It is better if they have gone back and looked at the results because you know they have a level of interest in the kind of condition that you are looking to get treated. If they are just guessing, if they can get a pretty good guess, it is at least getting you somewhere. If they can only quote literature, they either have not done many or they do not have much of an interest in it.

Dr. Cooper:
Interest in following up on their patients and seeing how well they are doing.

Dr. Ullrich:
Right.

Dr. Cooper:
Do most spine surgeons follow their patients over the next couple of years after doing a fusion surgery, for example?

Dr. Ullrich:
I typically would follow my lumbar fusions for a year and cervical fusions for about three months.

Dr. Cooper:
So you would get an idea at least of how they were doing after at three months for the cervical and a year for the lumbar.

Dr. Ullrich:
It is nice for a year for a lumbar because you actually get to see a lot of improvement between three months and a year. It gives you further feedback on how well they turn out in the end. Cervical fusions are fairly well done healing.

Dr. Cooper:
I wonder if it occurs or is possible for surgeons or any physicians to follow up longer term, even if it is a phone call after ten years down the line, and see how their patients have done and if they have a problem with an adjacent segment in their spine. Does anyone do that?

Dr. Ullrich:
We are doing it right now. We have 125 patients that we are following out longitudinally that have had an L5-S1 anterior lumbar inter-body fusion. We are looking at that to see how many people are going to need to be treated at the 4 or 5 level and hopefully we will even be able to bring them back to do MRIs at the next level.

Dr. Cooper:
It is a great piece of data to be able to offer somebody coming in, looking at a fusion, even though I suppose the technology will change over that time.

Dr. Ullrich:
It is interesting because we have been doing that for nine years right now and we have not had to do an L4-L5 level. So it does not seem to be as rampant as we were thinking. I am doing this because if we need to have artificial discs to save the next level, we should know if we are affecting the next level.

Dr. Cooper:
Absolutely. That is terrific data you have. It is a difficult position to put patients in, meaning to have them dobackground homework and make sure that they put in a context what their doctor is saying, in the sense that they double-check it. What kind of resources are available to find out about the type of procedure that they are going to get and also specifically to find out about the surgeon before they even get there?

Dr. Ullrich:
Unfortunately, finding out about the surgeon is mostly word of mouth. There are some government agencies now looking into rating hospitals, but I do not think they rate physicians yet. And some hospitals are definitely going to do better than other hospitals, especially if they concentrate on doing spine surgery. They will have lower infection rates, less time in a hospital and things like that.

Dr. Cooper:
One of the criticisms of rating between physicians and even between hospitals is that some physicians might take slightly more complicated cases depending on where they are. And there might be other factors going into it, making it difficult to make a head-to-head comparison. How do you feel about the idea of rating physicians or rating their surgical outcomes against each other?

Dr. Ullrich:
I think that is why it has not been done yet, it is very much a slippery slope and it is hard to do other than from set data, like the length of the stay or complications. But they do not account for how acute and how sick the patients were to begin with. I think in cardiac surgery they did start to do that. I do not think we have a rating, a classification system pre-operation, to say how sick somebody was before they had the surgery.

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