An injured athlete is sometimes faced with the decision to go under the knife to hopefully rid you of your pain once and for all. With the multitude of diagnostic tests available today it’s often very easy to be convinced that surgery is the only way you will get better, even if it’s exploratory surgery. After all, if you see a bulging disc on your MRI, then that must be the cause of your lower back or sciatic-type pain, right? Or maybe you’ve been told that the loss of joint space in your knee is the reason for your pain and that you need to go and have it cleaned out so you can get back to running again. “There’s just no other solution” is what many are often told. Well, surgery is sometimes necessary but more often, it is not. When the recommendation is that you go under the knife, you should not only think twice, but ask twice, get a second if not third opinion, and consider all other options. The often promised positive outcome is typically not as rosy as it’s made out to be.
What’s That Film Say Again?
Although technology is a beautiful thing it’s not guaranteed to give you a precise diagnosis or solution to your problem. Just because something shows up on a film (i.e., CT scan, MRI, X-Ray), it doesn’t necessarily mean that that is the cause of your problem. Often the problem is distant to where the symptom is felt, yes even in the case of something sometimes staring you directly in the face as a result of an image on a film.
Take, for example, the classic lower back disc bulge or herniation. If you have lower back pain and your MRI shows a disc issue, then it’s often easy for medical professionals to convince you that the disc is causing pressure, perhaps on a nerve, and hence your pain. But this very sane reasoning is why most lower back surgeries fail – the person has the disc or some bone removed so the pressure is relieved yet their back pain is little, if any, improved. How can that be? I’ve actually seen patients come in to my office with a disc completely removed that was supposedly putting pressure on a nerve yet by surgically removing this pressure, it resulted in zero pain reduction. Yes, zero. This might sound crazy but it’s more common than you think and this result occurs not just in spinal discs but in many other areas of the body too.
Who’s Reading What? Get a Second Opinion
Realize that any diagnostic test is only as good as the person who takes it combined with the observation of the one who reads it. It’s not difficult to miss something on an X-ray if you’re not set up properly by the tech and likewise it’s not too hard to cast a shadow that someone might read incorrectly as a problem or hide a problem for that matter.
Reading a film is very subjective. One radiologist reading a film may deem that a problem is better, or worse, than another radiologist. I remember one case many years ago where I saw this guy who traveled to see me for his back ailments. He brought his films and his report in with him. The report made it sound like the discs in his back were severely herniated, yet I couldn’t see that on the MRI. I’m no expert at reading MRIs (at least not to the point that a radiologist should be), so I decided to call the center where he had the films taken. Another doctor there was nice enough to review the films with me and he too couldn’t understand why the report exaggerated the case. The report noted “moderate” and “severe” disc bulging while the doctor I spoke to said he would classify them as “mild” and “moderate”.
So the take home message here is that it’s always good to get a second, if not third opinion especially if you’re thinking about surgery. You don’t need someone telling you after the fact that your problem wasn’t as bad as it appeared to be. Once your surgeon is at the area of concern, it is not likely that he or she abort the procedure if the problem doesn’t correlate with the report or diagnostic study finding.
Look at the Other Side
It’s not uncommon for someone to have a complaint and the area of concern shows something rather remarkable just by pure coincidence. In other words, how do you know if what was discovered during a diagnostic study wasn’t already there before you had pain or loss of motion? Maybe that’s just how you were made and now it’s being cited as the reason for your ailment or inability to heal. I’ve seen this numerous times and very recently by a student of mine’s son.
Recently, his boy fell and hurt his foot so he took him into the orthopedic clinic and they did an X-ray and the doctor came back in stating that he had fractured his sesamoid bone. The dad told the doctor that he didn’t see how that was possible given the way his son described hitting it. So he told him he wanted an X-ray of the other foot also. The attending doctor looked surprised at this, but the dad insisted that he wanted to see if his other sesamoid was also split in half (bipartite). Sure enough, the X-ray of his other foot came back and showed that the sesamoid was also bipartite. He told the doc he didn’t think he broke it after all and that it was most likely congenital. His wife also had a foot injury about a year ago and the doc misdiagnosed her with a broken sesamoid, when in fact she also had a natural bipartite sesamoid in both feet. So, this doc told him that regardless his recommendation for treatment was the same, which was to put him in a boot and give him pain meds and to follow up in two weeks. So much for that doctor listening, looking at the facts, and trying to figure out the problem presented before him.
Don’t assume that something you see is the whole or complete reason for the problem. This is also very common with arthritis in joints. I’ve seen X-rays of bad knees that clearly show loss of joint space which just must be causing the person’s pain. Yet, when they have the other asymptomatic knee filmed, it’s often been just as bad if not worse.
Exploratory surgery seems to be more common than you’d like to believe. Often, when a diagnostic film just doesn’t correlate with exam findings or identify a specific problem, the physician must use their own experience and hopefully a thorough exam to determine whether surgery is still necessary or not. Of course this aspect should always play a huge role in the decision process, as you should never go into surgery just because of a finding on a diagnostic test. (Yes there are exceptions of course – like a piece of glass sticking in your head.)
This Hail Mary approach to surgery is highly skeptical. If, for example, you are having shoulder problems and nobody can figure out why and a MRI, X-ray, or other study is unable to identify something remarkable, do you really want a surgeon to cut you open to see what they find? I realize that after perhaps months or years of pain and loss of mobility you may be at your wits end. Consider the possible consequences several times over because once you’re cut open, there is no turning back.
For two areas of the body – the feet and the jaw – I’d recommend that you are certain you have exhausted all your options even if that includes going to consult with some witch doctor on the top of a desolate mountain range. Those areas tend to be the most problematic when it comes to surgery; I’ve seen horror stories from botched TMJ and foot surgeries and some of them just can’t ever be properly corrected again.
If after you’re more informed by talking to more than one doctor and you’ve had your films thoroughly looked at, you’re still convinced you need surgery, you’ll want to know what to expect during and after surgery. In Part II I’ll discuss going under the knife, post-op recovery, and why more times than not, surgery won’t correct all your problems.