Checklist for patients considering Spine Surgery

August 5, 2022

Here are some critical questions a patient should be asking their spine surgeon before considering Spine Surgery.  Dr. Nordt has provided some additional insight on why these questions should be asked

Do I really need a recommended surgery ?

The question is if you need a recommended surgery, it has to do with the significant clinical findings, and significant weakness, numbness, incapacitation, and functional loss. The surgery is not based on an image or a picture, and if the doctor never takes your clothes off and never examines you, then you’ve lost that information.

What are the non-surgical alternatives to surgery and what are their risks and benefits ?

Basically a nonsurgical alternative, if you can do it, is just basically physical therapy, strengthening weak core muscles, weak muscles, restoring flexibility, and also clarifying where the pain is actually coming from, which is not done consistently.

The upsides and downsides of nonsurgical alternatives, unless you are going on a fast downward trend towards paralysis, or loss of muscle function or bowel or bladder function, you have time to exercise nonsurgical alternatives. As I mentioned earlier, physical therapy, strengthening, specifically core strengthening, anti-inflammatory medications, and possible use of medications to alleviate a back pain problem.

What are the upsides and downsides of the non-surgical alternatives (for example: less risky and cost (significantly) less) ?

But it depends on how the doctor presents it to you. If he’s conservative, he’d want to do everything possible to exhaust those alternatives before surgery is recommended.

How likely will my condition get worse if it’s not surgically addressed?

It might not be worse, it just won’t be better, and I think most people that become paralyzed go through the emergency room. If you’re seeing a doctor and he says, “It’s going get worse,” you have to ask him, “What’s going to get worse?” I think the worst-case scenario is that you just will not be resolved of this, and it’ll be a nagging functional problem until you resolve it, surgery or no surgery.

Can it be done minimally invasive as possible?

Well, in this day and age many surgeries are done minimally invasive. The question is if it’s necessary. A minimally-invasive surgery is very attractive to a patient without having to be admitted to a hospital, and that ends up maybe a “long road to a little house,” as I call it sometimes. So one must be careful about that.

What are the qualifications, background and motivation of the surgeon?

Generally a spine surgeon is an orthopedic spine surgeon or a neurosurgeon. Neurosurgeons are nerve doctors. They’re electricians. Many do not understand bone fusion, stability, instrumentation, fixing spines so they can fuse. An orthopedist is a functional construction guy, and can do something to fix it if it’s necessary. But just beware: The more you do in the back, the higher the charges go as far as money is concerned. So that has to be considered.

The motivation, basically if you have an employed surgeon, he or she are going to earn points (RVU’s), and the more points he or she makes, it better it justifies their salary at the end of the year, and bonus.

Is the surgeon really a medical doctor or specialist spine surgeon ?

Actually, generally a spine surgeon is a medical doctor specializing in spine surgery. So each one of those kind of eclipses each other. It’s one and the same.

Is he in good standing/are there any reports of malpractice or license suspension ?

That is researchable through methods that people have, and you can go online and locate this information. I believe that most doctors are quality people, but most are unfortunately trying to make a living for the employer that they work for.

Did the surgeon radiate genuine compassion during my case (did his or her body language and voice leave any doubt)? Or was it a rather pure technical procedure discussion and perhaps with emphasis on the needed costs ?

This is an excellent question. It’s a little bit generic, and little difficult to nail down. But the perception of how interested the doctor was to help you rather than help you do the surgery can be perceived by many patients. Patients unfortunately, (or fortunately,) trust doctors, and by trusting doctors, you tend to go with what they say. I’d just be concerned and be wary, that’s all.

Did the surgeon take the appropriate time to look at my case in detail ?

Well, he or she had to look at your history, ask you questions. Do you hurt when you stand, sit, or lie down? Do you have leg pain or back pain? And looking at your case, but also underscore a conservative treatment that failed and proper tests that’ll be done after all this happens.  Was it proper examination?

Did the surgeon properly examine me according to best medical standards:

Well, the medical standard is you are disrobed, your reflexes in your lower extremity and upper extremity are checked, the muscle weakness in each muscle group is checked, the ability to move your spine left and right, up and down, and forward is all examined. And to delineate the best medical standard to examine is a little bit beyond the scope of this, but one needs to do it on a regular standard basis to prove that something exists or doesn’t. In my practice, I rarely find neurological problems, but I do a thorough exam in order to make sure that doesn’t exist.

Was there was a detailed medical history taken? Was a proper examination performed? Palpation, functional tests and perhaps extra tests being performed before deciding spine surgery was the best option? Or was it quick superficial discussion where I even did not undress (so not even my spine is properly observed)

I think that if no one disrobes you and the doctor himself does not examine you, then it’s not a thorough examination. An MRI is usually done as a screening test for surgery, and 35% of them can be worthy of surgery but there’s nothing wrong with the patient. So it’s very important to have a deeper discussion about what’s causing the pain exactly. You can’t just gloss over it, because I think all patients are bright, intelligent, and a little bit of education can alleviate their anxiety.

Is the surgeon welcoming to interdisciplinary work with others: physicians and therapists ?

That remains to be seen. It depends on what the doctor’s cooperation is and whether they are allowing it.

Does the surgeon have a primarily financial interest to perform a surgery ?

The financial interest of fee for service, a lot of doctors don’t get any money for fee for service, so they sign up for the hospital or in a medical institution who pays them a salary based on the points they make. So the more points they make, the more it justifies the salary, and you can figure out what’s going on from that point on. Because the more they do, the more they get, and that’s true.

In an auto accident scenario many times this has to do with manufacturing a diagnosis in most cases, in my experience, and creating a value to the case based on surgery or a diagnosis is really not realistic.

I think having attorneys refer patients to a facility are not necessarily the strongest referral pattern. I also say that if you go to a chiropractor and your neck or back is manipulated three times a week for three or four weeks or months, that proves in my book there is nothing wrong with the neck or back. So I use that as a screening test.

Is the surgeon part of a Physician Owned Distributorship?

Well, a physician-owned distributorship means he owns part of the company that is selling the instrumentation, the screws, the rods and all that. If that’s the case, then he gains some financial compensation because of that. There are specific laws and rules federally and otherwise to prevent that, and several doctors have actually been sanctioned severely with jail time because of that inappropriate relationship.

Does the surgeon hold large stocks in a medical device company ?

The stocks in the medical device company should be a matter of record and they should disclose them to you.

Is the surgeon receiving any other forms of compensation from the medical device industry?

Well, if you own a hammer and everything looks like a nail, then you buy the hammer. It’s not hard to figure out. I think the altruism and the ownership of our noble profession is really dependent on each individual surgeon’s response and respect for what he does.

Is the surgery based purely on MRI findings or other diagnostic images or has the whole clinical picture been examined ?

If an MRI is purely the diagnostic image, then there’s a flaw there because it has to match the clinical findings. If one is never examined, one doesn’t know what the clinical findings are. And the sad part is that, as I said earlier, 35% of normal people off the street will have an MRI that could justify surgery and there’s nothing wrong with the patient. So a lot of inappropriate surgeries are done, over 600,000 or 800,000 a year on people who do not need the surgery that was done, and it has to be other criteria that have failed before one even moves to surgery.

Has there been much effort to avoid costs related to medical imaging (or has it been quickly and easily been ordered)? Also have I been informed well about cheaper alternative diagnostic tests ?

Generally speaking, ordering it quickly is a flaw because clearly it’s a red flag, because they’ve not examined you and they wanted to have a quick assessment of what’s going on. So I feel that the imaging can be a part of the doctor’s compensation if he’s employed with a medical institution or with a hospital.

Does the surgeon try his best to avoid surgery ?

All I can say is one would hope so.

Did the surgeon explain to me in detail the potential risks and benefits?

That should have happened. I do that on a routine basis, and there’s ups and downs to the whole thing, including infection, failure, loss of fusion, etc. The patient should be informed of this by the physician.

Has there been undue influence on me, ie; Did the surgeon attempt to provoke fear about consequences if I do not get surgery quickly? Did the surgeon try to quickly convince me into surgery ?

Generally surgeons will say something outlandish like, “If you don’t get this done, you’ll be paralyzed in the next day or two,” and that’s absolutely not true. I’ve been to meetings after meetings after meetings, and that is absolutely wrong. The undo influence is just talking somebody into something when in fact there’s no legitimacy to go forward with that.

How many times has the surgeon performed this surgery?

I think if someone has had a fellowship trade and performs these on a regular basis … I won’t go into numbers, because a lot of times the numbers are higher than the legitimacies of the surgery. But on the other hand, the technical aspect is pretty good. The question is: Are you going to get the result that you want at the end of the day with a surgery that is done? He may have done it technically competently, but inappropriately to the problem.

Is the surgeon known to follow up closely with patients after surgery ?

Unfortunately with doctors that work for hospitals, most doctors see people the day before and the day after, and the hospital makes money on all the peripheral referrals of hospitalists, physical therapists, and they make money on the side. So unfortunately the hospital does make money and the surgeon indirectly makes money with all the tests that are ordered, and should follow up until three months have gone by.

Did the surgeon react in an angry/offended way when I mentioned to get a second or even third opinion instead of immediately following his or her advice ? Did the surgeon stay calm and happily explain their decision making process, even encouraging me to be well informed and get other opinions?

This is a very interesting conundrum. Defensiveness by a highly egotistical surgeon is not uncommon. But they should be able to settle down, explain what’s going on, (and calmly explain it to you,) and easily accept a second or third opinion because that’s your body and that’s your surgery, and you deserve to have the correct answer.