Which is Worse: Operating on the Wrong Leg or the Wrong Person?

April 25, 2012

Dr. John Wennberg, Founder and Director Emeritus of The Dartmouth Institute for Health Policy and Clinical Practice, has asked: “If operating on the wrong leg is considered a medical error, what do we call operating on someone who doesn’t need surgery?” Operating on the wrong leg is every surgeon’s (and patient’s) worst nightmare, but Wennberg infers that operating unnecessarily is of even greater concern.

Though an orthopedic surgeon, my long-term interest has been the non-operative care and research of painful spinal disorders. My concern is how often clinicians are either unaware of, or perhaps ignore, a unique and highly informative type of clinical evaluation that often identifies a mechanical exercise treatment that provides rapid, full, safe, and inexpensive recoveries, even for those considered as candidates for some type of disc surgery.

This mechanical paradigm of care is appropriately known as “Mechanical Diagnosis & Therapy” (MDT), developed by Robin McKenzie, a New Zealand physiotherapist. These innovative methods are currently taught in 40 countries with multiple studies reporting high inter-examiner reliability.

In a blog entitled “Rescued from a Near-Surgery Experience”, I described a man with severely painful and disabling sciatica. Days before his scheduled disc surgery, he was provided the opportunity to be examined using MDT methods that revealed that his problem was correctable using very simple spinal movements that first eliminated his leg pain followed by his low back pain.

In 1986, a study reported the same result in a cohort of 67 patients with sciatica and neurologic deficits (Kopp et al., 1986). They were all introduced to a portion of this testing as their final pre-surgical screening. This enabled 34 (52%) to eliminate their own pain and regain their full spinal movement in just five days, naturally avoiding surgery. Five years later, 60% were found and surveyed: none had undergone surgery (Alexander, 1992).

So 52% had an easily reversible disc disorder, while the rest did not. All but one of those underwent disc excision surgery. But these two subgroups were obviously very different, despite having the same clinical presentations and even the same anatomic diagnoses. If they had not been mechanically tested in this way, most would have undergone surgery, but half would have been unnecessary.

Three other studies report the same high prevalence of reversibility in pre-surgical patients with a similar reduction in surgical rates when the MDT evaluation was introduced. This provides a convincing argument that withholding this inexpensive form of testing contributes to a substantial volume of unnecessary disc surgeries. Unfortunately, only a small percentage of physicians and surgeons utilize this form of assessment, so a substantial percentage of disc surgeries are unnecessary for those with the undiscovered ability to recover quickly and inexpensively.

But let’s take this one step further. If this same MDT testing is provided soon after the onset of patients’ low back pain episodes, many studies report that rapid early recoveries are even more common, in as may as 70-90% of cases, thus eliminating the need for any further care, disability or cost (references available).

Currently, the most commonly recommended alternative to having disc surgery is to simply remain active and try to slowly increase activities as pain permits. These recoveries are slow, often taking 6-12 months or more, and often incomplete. Informing pre-surgical patients of this option is the basis for “shared decision-making” (SDM) programs intended to present a balanced view of surgical and non-surgical options.

In contrast, MDT care enables full recoveries in just days or weeks, including in many pre-surgical patients. Those with the findings of a rapidly reversible disc problem are clearly the wrong people on which to operate. Yet this information is not included in SDM presentations. Yet how can patients make quality decisions about surgery without this information?

Other studies report that advanced imaging and surgical rates, technology innovation, and costs for spinal disorders are dramatically increasing….but with no reduction in re-operation rates. Alternatively, so much can be learned about how to improve outcomes from simply examining the patient…..mechanically. But how old-fashioned! Where’s the glitz and money in that? After all, we assume that complex health care problems all require sophisticated, high tech interventions. Don’t they?

Not surprisingly, such rapid, non-surgical turnarounds are of little interest to clinicians invested in providing their favorite treatments, whether non-invasive or invasive, despite so many validating studies (references available).

But even economic bias must be subject to the Hippocratic mandate of “do no harm”, always do what’s best for the patient, and consider their welfare before self. So how do we justify offering surgery to a patient who can recover easily without it? It’s done by ignoring or withholding this MDT evaluation.

Let’s reserve surgery for those who really need it and avoid operating on those who don’t.

Ron Donelson, MD, MS is a consultant to healthcare providers, large employers, and health plans, helping them improve the value of their musculoskeletal care. He blogs at SelfCare First, conducts live webinars, and has written a book specifically for clinicians, researchers, and payers entitled “Rapidly Reversible Low Back Pain”. 


2 Responses to “Which is Worse: Operating on the Wrong Leg or the Wrong Person?”

  1. […] the need to identify ways to implement objective decision-making, I’ve reviewed in other SCF blog postings multiple published studies that report that, not only are 50% of disc surgeries performed […]

  2. […] real life decision is when to operate, not which is better? Surgery is never a good choice if there is still a non-surgical treatment […]

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