In the original Karate Kid, Daniel Larusso’s sensei, Mr. Miyagi, heals injuries immediately with a mysterious manipulation trick. “Well can you fix my leg… with that thing you do?” Even with a ghastly knee injury, a quick hand rub and daunting music allow Daniel-San to return to the mat within 15 minutes and overcome the Cobra Kai in the tournament. Without an exam, Mr. Miyagi just knows what the injury is, and how to immediately fix it.
In neurosurgery, we commonly see patients in the clinic with spine pain and sometimes neurologic deficits, very early in their course. With just a few days or weeks of symptoms, general practitioners are routinely referring for spine surgery evaluation. Despite abundant literature highlighting that with 6-8 weeks of observation, spine symptoms will often dissipate on their own (even weakness can improve with time in about 80% of patients with simple observation), general practitioners may fear their patients will consult another practice if their expectations are not met. Additionally, there is a common concern that postponing diagnostic and therapeutic interventions would make patients feel their pain was not being taken seriously. In other scenarios, patients are commonly referring themselves to specialists based on their own internet research. They often self-diagnose and believe their condition has an immediate surgical indication or quick remedy. “Maybe those other patients can wait and get better, but my condition is different, serious, and needs to be fixed.” Despite the common American being educated, medical literacy is fairly low.
Sometimes, further imaging is needed or diagnostic interventions to help find the pain source. Other times, it may be suspected that nothing further is needed, since the natural history of many spine problems is spontaneous resolution. However, being told that nothing should be done, other than observation, is seen as the most disappointing outcome of a pain consultation. The majority (~64%), expect further investigations, and about 48% expect changes to their medications.
Unfortunately, there often is no ancient Miyagi-like option in the neurosurgical armamentarium. Rarely is surgery immediately offered, and when it is, surgery often takes weeks to schedule. Routinely physical therapy and possibly injections are sometimes prescribed, which also commonly take a few weeks to be approved through insurance and then scheduled. Their effectiveness often takes weeks to months longer to achieve. Fewer surgeons are prescribing medications, especially since preoperative opiate use has been shown to predict poor surgical outcome. Chronic back pain is not improved with narcotics. Often, a good surgeon will simply say, “Let’s wait and see how this goes on its own”. Observation is an actual treatment, and not dismissal.
Frampton T et al. What do patients expect from their first visit to a pain clinic? Clin J Pain. 2005.
Weckbach S et al. A survey on patients’ knowledge and expectations during informed consent for spinal surgery: can we improve the shared decision-making process? Patient Safety in Surgery. 2016