“Doctor Smith told me that if I didn’t have surgery in the next week, I would be paralyzed.”
I just love this one. And I hear it all the time. It’s a sales tactic used by surgeons to goad individuals into signing on the dotted line. For the record, I’ve never said that to a patient, as it is simply untrue in the vast majority of cases, at least anecdotally. Until now…
Much of the peer-reviewed literature is impractical from a clinical standpoint and simply an outlet for the primary author’s ego. Often times a permutation or frank reiteration of existing studies, research lacks the “trench” value craved by practicing physicians, a “take home” message if you will. Journals entries have a habit of catering to a select physician cohort, those interested only in a small subset of neurosurgical pathology, thereby eliminating the mass of us, who tend to the masses.
Degenerative disease of the spine or “arthritis” is by far the most commonly addressed neurosurgical pathology globally. Hundreds of thousands of spinal procedures are performed each year worldwide. And as the proportion of aged individuals increases, the manifestations of degenerative disease will become more readily apparent. More surgery will be performed statistically speaking, right?
Logic would dictate that the older one becomes, the more likely he or she is to require surgery due to the unremitting advancement of spinal degenerative disease. More time on earth, more disease burden, an increasing likelihood of surgery. Across the board.
The question then becomes, “What true percentage of these individuals deemed to need surgery actually need it?” The data are difficult to parse given their multi-factorial nature. One thing can be said however, there tends to be an egregious surgical stance towards degenerative disease of the spine, both lumbar and cervical. Surgery for the sake of surgery, in essence. Surgery in the context of advanced degenerative disease albeit in the asymptomatic patient. Does this make sense? Treating the MRI scan and not the patient? An emphatic NO. And this is exactly what was borne out in a recent study published in the peer-reviewed journal Neurosurgery.
Cervical stenosis patients are commonly advised to undergo surgery due to the “risk” of spinal cord injury after a future traumatic event. But what is the true risk? Quite low in fact. Between 2009 and 2014, 55 patients with significant cervical stenosis managed non-operatively were asked standardized questions including: 1) whether a previous physician recommended neck surgery 2) whether a physician indicated that they would become paralyzed after a traumatic event, and 3) whether they experienced a traumatic event during the follow-up period. Here are the findings:
- A total of 31 patients or 56% were previously told by another physician that they needed to undergo surgery on their neck due to the spinal canal narrowing.
- 26 patients or 47% were told by another physician that they would be paralyzed after a motor vehicle accident (MVA) or fall unless surgery was performed.
And guess what? Of the 10 patients that sustained either or a fall or were involved in an MVA during the 5-year surveillance period, NONE developed paralysis nor a spinal cord injury. Hmm…
This observation is consistent with the data from a 14-year retrospective (the above study was performed prospectively) study with a large cohort demonstrating a 0.35% incidence of cervical spinal cord injury in the wake of a MVA. Not zero, mind you, but far lower than expected. And in the face of widely accepted treatment paradigms.
Long and short of it? Think twice (or more) before committing to surgery based upon radiology alone. Aside from carotid endarterectomy, there are few “prophylactic” surgeries of merit. In the context of cervical spine surgery, the data simply do not pan out. The benefits simply do not outweigh the risks.
Truth hurts, doesn’t it? Or maybe no longer, literally speaking…
Sources:
- Chang V, et al. The risk of acute spinal cord injury after minor trauma in patients with preexisting cervical stenosis. Neurosurgery. 2015;77(4):561-565.
- Stein DM, et al. Occupant and crash characteristics for case occupants with cervical spine injuries sustained in motor vehicle collisions. J Trauma. 2011;70(2):299-309.