“To see others suffer does one good”
– Friedrich Nietzsche
Schadenfreude, the enjoyment of another’s misfortune, first appeared in English writing in 1853. Other languages have similar phrases. The Japanese have the proverb, meshiuma- “The misfortunes of others taste like honey.” The French have, “joie maligne”. The Danish talk of, “skadefryd”. The Hebrew saying is, “simcha la-ed”. In Russian, its, “zloradstvo”.
Many patients avoid a spine surgeon’s office having been told that surgery will make them worse. There’s the pervasive notion that once someone has surgery, their spine will never be the same, they may be worse off with chronic pain, or that first surgery invariably leads to multiple future surgeries.
So is this pessimistic perception of spine surgery real, or is spine surgery dissuasion just Schadenfreude? Is this some subconscious sadistic ploy by detractors?
Low back and leg pain (“sciatica”, or radiculopathy) is often caused by nerve compression in the lumbar spine. When the nerves are compressed and not functioning correctly, symptoms include pain, weakness or numbness.
The most common causes for nerve compression are disc bulges/ herniations, lumbar joint (facet) enlargement, or surrounding ligament (ligamentum flavum) enlargement. Other causes include spondylolisthesis or scoliosis.
Treatment for back and leg pain is usually conservative, with medications, therapy and injections. Non-operative treatment is often helpful in about 70-85% of people over 6-8 weeks. Few patients truly are candidates for surgery.
Surgery for lumbar arthritis, without instability or spondylolisthesis, often involves lumbar decompression. The indications usually include failure of at least 6 weeks of conservative care, progressive weakness or numbness, or such severe and debilitating pain that non-operative care is not possible.
Contrary to its less-than-ideal reputation, it’s been known for awhile that lumbar decompression surgery actually does a good job in treating back and leg pain. Factors contributing to poor surgical response include co-existing psychological problems, litigation or compensation seeking behavior, and smoking. Even in obese patients, outcomes seem favorable. It appears that leg pain responds much better than pure back pain in lumbar decompression.
The SPORT (Spine Patient Outcomes Research Trial) study began in 2000 and its 2006 results shocked the spine community. The trial was possibly run by surgery naysayers, potentially out of Schadenfreude, seemingly to prove that spine surgery wasn’t beneficial. However, one and two year results showed that surgery provided quicker symptom relief at 1 and 2-years compared to observation, and surgery resulted in improved physical function and patient satisfaction. We now have the 8-year outcomes of SPORT, which still seem to show that carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than conservatively treated patients (Another arm of the SPORT studied fusion and showed similar findings).
This month in the New England Journal of Medicine, another larger sample of 128 patients (Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 months) from a single center showed that lumbar decompression improved sciatica (lasting more than 4 months) compared to nonsurgical care.
So yes, lumbar decompression surgery is very beneficial for some patients. And of course, surgical dissuasion by some is not really Schadenfreude… most everyone treating spine conditions simply wants the best outcome for their patients. We just all suffer a bit of hubris sometimes and fall in love with our own flavor too much. There is always a grayish line between conservative and surgical medical opinions. Schadenfreude and sympathy are not always either/or:
“That strange sense of inner satisfaction that always manifests itself… when someone is afflicted by a sudden catastrophe; a sensation that not a single one of us is proof against, however sincere our feelings of pity and sympathy.”
– Dostoyevsky, “Crime and Punishment”