Do You Need Surgery for Lower-Back Pain?

A former orthopedic spine surgeon empowers patients who have chronic pain to connect with their own capacity to heal.

A collage of a spine in pain and a book cover

David Hanscom, MD, knew he wanted to become an orthopedic spine surgeon the day he started medical school. Part of a 1980s movement embracing lumbar fusions as the best solution for chronic lower-back pain, Hanscom believed he could rid people of their spine problems with his surgical skills. In the first years of his practice, he enthusiastically prescribed and performed spine fusions on patients with lower-back pain during the first years of his practice.

But when a study of Washington state workers’-compensation patients showed a shockingly low success rate for lumbar spine fusions, Hanscom stopped performing the procedure and began seeking alternatives.

Years of research and his own personal experience suffering from chronic pain led Hanscom to realize that the secret of patient care — caring for the individual patient — had become lost in mainstream medicine. As a result, he developed his own treatment paradigm grounded in connecting with each patient’s capacity to heal.

Every year, hundreds of thousands of people undergo spinal surgery, according to one recent analysis, but Hanscom’s Direct Your Own Care (DOC) program has helped hundreds of patients minimize or eliminate their pain without surgery. His most recent book, Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice, provides a framework for understanding if and when spine surgery is right for you. We reached out to him recently to talk more about lower-back pain and his program.

Experience Life | How would you describe the DOC approach?

David Hanscom, MD | The DOC process understands that chronic pain is a memorized set of circuits in the brain that become connected with more and more life experiences, and the memory can’t be erased. Anxiety is not psychological. It is a physiological response to a threat, which creates a flood of stress hormones in your body. Sustained levels of these hormones translate into over 30 possible physical symptoms. So it’s a neurochemical problem, and you can’t solve it with surgical procedures.

But it is a solvable problem. The medical world is holding it out there that you have to live with it, and that is simply false. It doesn’t matter what the source of the pain is; it is possible to rewire the brain around the pain. It is a matter of time and repetition.

Research shows that hope and optimism contribute to healing. The three aspects of solving chronic pain are:

AWARENESS

  • of the nature of chronic pain
  • of your diagnosis
  • of the principles behind solving it

DEALING WITH EVERY ASPECT OF IT SIMULTANEOUSLY

  • Most treatments help decrease pain, but none solve it when used in isolation.

PATIENT CONTROL

  • Since each person is so unique and complex, the only person who can solve it is the patient.

EL | How did you come to develop this approach to chronic pain?

DH | I’m an orthopedic spinal surgeon[, which is] stressful because people expect perfection. There’s no room for error in it.

My attitude [early in my career] was, Bring it on. I went to one of the top spine fellowships in the world at the time, and I [started practicing].

I actually did not know what anxiety was, but one day, I was trying to cross the 520 Bridge in Seattle at about 10 p.m., and I went from no anxiety to having a panic attack. And that started a 13-year tailspin that I could not pull out of. I experienced — among other symptoms — migraines, severe anxiety, burning feet, PTSD, insomnia, and pain in the neck, back, and chest.

I was in psychotherapy for 13 years trying to solve this, [but it did not work for me.] Then in 2002, I picked up a book that recommended writing down thoughts in a structured way. When I did, I felt a shift and a slight decrease in my anxiety for the first time. I learned some additional treatments, such as mindfulness, relaxation tools, bringing a mindset of play into every aspect of my life, and most important, forgiveness. I did not even know I had anger issues. I was just “always right.” Six months later, my anxiety had dropped dramatically and I was free of pain. All of my other symptoms disappeared. I began to share what I’d learned with my patients and watched many of them improve, too.

EL | Do You Really Need Spine Surgery? is your second book; your first book was Back in Control. How does your most recent book build on your work presented in Back in Control?

DH | It has been known for decades that there are multiple risk factors for bad outcomes from surgery. They include:

  • a long time on disability
  • untreated chronic pain
  • anxiety
  • depression
  • anger
  • insomnia
  • poor nutrition

We put together a rehab program that was largely self-directed for patients to complete before any elective surgery. Many surgical patients canceled surgery because the pain resolved, and the surgical outcomes were more consistent for those who did have surgery. Back in Control is the foundation, and Do You Really Need Spine Surgery? answers specific questions about the role of surgery in solving a given person’s pain. 

EL | In your book, you frame your approach to spine surgery around something you call a treatment grid. What is the treatment grid, and how can a patient use it to determine whether or not they really need spine surgery?

DH | It came about from a talk I gave at North American Spine Society in 2006. I realized that one of the biggest problems we have in spine surgery is people operating on normal spines where there’s actually nothing to fix. The biggest idea for this particular book is to say, Look, if there’s nothing surgically wrong, then surgery’s not really a choice. Whereas most surgeons — including me, historically — say, “Well, everything else has been tried. Let’s just try surgery.”

So, I made a distinction between structural, which means you have an identifiable anatomical abnormality, like a tumor or infection, with matching symptoms, versus nonstructural, where you just have nonspecific symptoms or you can’t see anything on a test that was abnormal for a given person’s age. In that scenario, we don’t know where the pain is coming from, so it isn’t logical to think a surgery would work. I also looked at whether the nervous system is calm or stressed.

If you have a structural problem with a calm nervous system, surgery works pretty well. If you have a structural problem with a stressed nervous system, the data shows that, actually, surgery could actually make it worse if you don’t calm down the nervous system first.

The group with nonstructural problems and a stressed nervous system convinced me that the mental pain is a bigger problem than the physical pain. Most chronic pain essentially comes from the mental threads of unpleasant thoughts, which elevates the levels of stress hormones. Anxiety is simply the sensation that results from these chemicals. To decrease anxiety, you must lower the stress hormones. But what medicine has missed is that this powerful unconscious feeling is not subject to rational interventions. Psychological problems arise in trying to cope with this sustained unpleasant sensation. They also have missed that this unfavorable chemical environment translates directly into physical changes in your body. We have known for more than 50 years that chronic stress causes serious illness and disease.

So, the first goal in my book is to say, Look, if you can’t see something to fix, don’t do it, period. It’s just not an option. I’d like to see the trend of operating on normal spines stop. And the second goal, of course, is that I’d like to share the healing principles with [more] people. It is not difficult and is largely done on your own.

EL | What kind of response have you received from your work?

DH | There’s a small group of physicians that are excited about it. The surgeons have little  interest so far, but that is shifting. But who really dislikes me a lot is administration.

In the old days, the administrators were accountable to the physicians. There were also chiefs of staff, and everybody sort of kept things in line. Physicians are now accountable to the administrators, and what they’re doing is they’re pushing us harder and harder to be productive, which means they’re pushing us to do procedures that are profitable but don’t work.

I actually quit spine surgery to do this because I was seeing three to five patients every week being badly harmed by spine surgery, and then I saw these other patients who go pain-free with, essentially, no risk and essentially no cost.

So, administrators don’t like this. Medicine, the business of medicine, is absolutely obsessed with production, and it’s a huge problem.

is an Experience Life assistant editor.

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