Transcription:
Do You Have Persistent Pain Even After Surgery

Prakash Chandran: There are times when we undergo a surgical procedure to improve our well-being that unfortunately results in pain that just won't go away. It's important to understand why this happens and effective ways to address it if it happens to you. We're going to talk about it today with Dr. Haroon Choudhri, a neurosurgeon at St. John's Riverside Hospital.

This is Riverside Radio HealthCast, the podcast from St. John's Riverside Hospital. I'm Prakash Chandran. So first of all, Dr. Choudhri, it is great to have you here today. let's just get right into it. What exactly are the main causes behind ongoing pain after surgery?

Haroon Choudhri: Sure. You know, one of the things about spine surgery is that unlike a lot of other parts of the body, there's no exact manual. And two patients with the same problem might be treated very differently by different surgeons. Now, that's a reflection of the fact that most surgeons will bring their experience and judgment into the decision-making. But as a patient, no doubt, it's somewhat unnerving, because they don't necessarily want the right answer. And someone may undergo a procedure and it may not wind up with a result that they wanted.

I think that there are several common patterns of patients who don't get better after surgery. I've been taking care of a number of patients over the years, and my specialty is revision spine surgery. And while it's understandable that every patient wants a good outcome from the surgery, there are other principles involved as well in that sometimes the surgeon will say, "Let's start with a more basic procedure and then perhaps a more elaborate procedure is needed later on."

if your car has low air in one of the tires, someone might say, "You need a new tire," someone else might say, "We'll just put some air in there first." You might put some air and then the tire will come back down and you go on to get a tire replacement. It doesn't necessarily mean it was wrong to do the more limited effort first. And it could have been known in the beginning that a tire replacement was necessary, but that's not always the case. Like if the tire is shredded, well, then putting air in there, you're just fooling yourself. And sometimes people will go for a minimally invasive or laser-based procedure because it sounds good and sounds appealing, but it's pretty clear that a careful analysis would suggest no, they need a more elaborate procedure.

Other patients, it's very appropriate to start with a basic procedure, particularly older patients or patients with other medical problems. And then if the patient doesn't do well, the patient and the surgeon have to work together to try to figure out, "Well, was there a more elaborate plan to begin with?" I try to talk to my patients in advance if I'm going to be doing a more limited procedure and say, "Hey, more necessary in the future, but for the following reasons, we feel that you'll be better off limiting it to this focal procedure to start out with."

Prakash Chandran: So, one of the questions that I'd like to detail a little bit more is let's say you get surgery and you get that more basic procedure that you're talking about and you do have pain afterwards, I think that for a lot of us, we'd be like, "Well, I don't want to go back to that same surgeon," but just thinking out loud, it feels like that surgeon probably has the best understanding of the circumstances of why they started with that more basic procedure to begin with. So can you speak to that a little bit?

Haroon Choudhri: Well, I think that's a very good question. Now again, I talked about the fact that surgeons will approach the fact that a given condition can be treated in different ways with the fact that they had their experience in judgment. Some surgeons are not trained to address deformity as well as simple decompression and they'll limit their procedure or their options to what they do best, which is not necessarily a bad thing.

But if you have someone, who doesn't get better, it might be that someone with a different range of experience or particular experience dealing with some of the challenges of revision surgery might be a better option.

Prakash Chandran: If I can summarize it, regardless if you are going in for an initial surgery or you're going in for a revision, it's really important to get multiple opinions because to your point, every surgeon's approach is different. Is that correct?

Haroon Choudhri: That's exactly right. I think it's very important to get multiple opinions and I encourage all my patients or make them at least free to get other opinions, acknowledging that I don't know everything. I don't have a crystal ball. I don't have a magic wand. And there are different surgeons with different perspectives. They can bring good information to it.

On the other hand, it is important if you're having a second surgery to think about going to someone who has experience doing it. And an analogy I give to my patients is there are some people who build kitchens and some people who remodel kitchens. And if you're remodeling a kitchen, you've got to deal with the fact that the gas might be on one side and the water may be on the other. You've got to work with those limitations.

Now, someone who's good at doing the remodeling is very good at doing something from the beginning, because they're not going to make a rookie mistake. They're going to put the washer next to the dryer. So as someone who does a lot of revision surgery, I think it teaches me a lot of what doesn't work and a lot of things to look out for. So that when I do an index surgery or a first-time surgery, I'm much less likely to have some of these basic mistakes, because I've seen what works and what doesn't work.

Prakash Chandran: I really love that analogy that you gave, and it really gives a clear understanding of what revision surgery is and why you kind of net more experience when you go in for that first-time surgery. So just detailing that a little bit more. what are some of the most common things that you have to go in and repair?

Haroon Choudhri: Well, one of the things I see a lot of is hardware malposition. And again, I don't say that to slight the surgeon. Sometimes screws don't look pretty on an x-ray, but that's what was necessary. Sometimes it's difficult to image, particularly a larger patient and so on. And sometimes things wind up where they weren't intended.

But in looking at a lot of patients, literally thousands of patients who've had prior spine surgery and try to decide, is there anything that can be done to help them? What I find is the three broad categories of problems. First category is either too much surgery or too little surgery was done. And I don't say that to fault the surgeon. Sometimes a more limited approach as we talked about earlier is what's recommended. Sometimes we don't know how bad a tumor is or how many levels are causing the pain and the different plan might be instituted. A lot of times I'll go back and I'll say, "You know, I would've done a little bit more," right? I look at someone who's had previous surgeries and, "You know, I would've done a little bit less."

A lot of times I'll say, "Look, I'll do the same thing." And that leads us to the second category of problem. Sometimes the disease keeps coming at you. People who are 10 years out from a surgery can have another problem. I always tell patients, "You know, when you change your flat tire and there's no guarantee one of the other three won't go bad as soon as you leave the garage." Now, if you drive on a lot of bad roads and the tires are kind of worn, you might not be surprised if another one goes bad in the near future. And when you have the car up there and you're taking a look at all the tires, you don't want to unnecessarily change out tires that have just a little bit of wear and tear, but there are other tires that you're going to say, "Hey, this is pretty bad. If I leave this, I'm almost certain to see this car come back or this patient come back in the near future."

Another consideration is a lot of times surgeons are trying to rush patients to get better, which is a good thing, but they'll trade away long-term durability of the surgery. So the patient will be very good right after the surgery. "Doc, you're a genius. I feel great. The incision is so small," and then three months later, predictably, another problem comes on and then they say, "Oh no, the surgery was great. Now we have a new problem." Well, a lot of times it's the same problem and it just wasn't treated more robustly enough. Sometimes a patch isn't as good as a proper repair.

And the third broad category of problems, which leads patients to come back with suboptimal results is when you didn't have good imaging to begin with. A lot of times, an open MRI is not adequately detailed to show the problem, or sometimes the patient doesn't get better, because they didn't really have detailed enough imaging or workup to see all the potential problems and all the nuances prior to their initial surgery.

One of the things I tend to do with both my initial surgeries and my revision surgery to get a fairly good quality set of images and consider both alignment and decompression problems. You know, there are two broad categories of problems in the spine. You can have something pinching a nerve of the spinal cord, whether it's a disc, a bone spur, a tumor, and you can have instability from either a fracture or a worn joint or a bad alignment.

Well, historically neurosurgeons have taken care of the decompression. The solution for a pinching of a nerve of the spinal cord is to decompress the spine like doing a discectomy. The solution for malalignment or instability or a fracture is stabilization or fusion like a scoliosis surgery or fixing a fracture. But really one of the things I learned the first day of medical school at Columbia University was the patient never read the book. Many patients have elements of decompression or instability. And if you address only one, even if you do it well, you may make the other worse or neglect to realize that there's another thing that's causing the patient's pain and problems.

I happen to have had dual training. I'm a neurosurgeon, but I also had a full orthopedic spine fellowship. And that perspective from both camps has really allowed me to see patients a little bit differently than someone who's only been trained in one camp or the other.

Prakash Chandran: Yeah, that holistic approach definitely makes sense. And, obviously, you know, kind of having that perspective when you're both evaluating or you're going in for a revision is super important. you know, I think a more basic question I wanted to ask is if underwent surgery and they are experiencing pain, is that something that is normal? And I know you, listed a lot of reasons why it happens, but if someone is listening to this for the first time and they're experiencing pain themselves, you know, what advice might you give them about what they're experiencing and what they should do next?

Haroon Choudhri: That's a great question. Now, there is a range of normal and expected pain and abnormal pain. And it's difficult because someone with experience in taking care of patients who've had prior surgery can see right away that, "Hey, this is normal. This is abnormal." For example, you can have a floor with 10 women in labor and delivery. They're all going through labor and they're all screaming in pain. An experienced nurse midwife or obstetrician can pick out one scream out of the 10 and say, "No, something's wrong in that room." It's the same way. A dermatologist can look at them one mole and say, "I don't like the look of that one. Something's going on there."

As someone who's taken care of and spoken for hours with patients who've had prior surgery and didn't have a good result as well as patients who have the normal pain, I feel I have a pretty good perspective on what pains are normal and to be expected and what are warning signs and what are hints that, "Hey, you really shouldn't be feeling this. Maybe we should take a more careful look."

Prakash Chandran: Yeah, that completely makes sense to me. the next thing that I wanted to ask was just around what people should aspire to in terms of pain. You know, after their initial or subsequent revision surgeries, is there ever a point where they can truly be pain-free?

Haroon Choudhri: That is the desire. And I have many patients who've gone through years of pain, had dozens of surgeries, literally dozens of surgeries, who have eventually become pain-free. There are many other patients where that's just not going to happen, but you can at least control it. And I try to talk with my patients beforehand to set reasonable expectations and say, "Look in my hands, I don't think you're going to be pain-free, but I think we can achieve your goals."

And I set personal goals for every patient. Some people say, "Look, I want to go from my front door to the curb to walk my daughter to the bus when she's going to get picked up in the morning." And this woman, she couldn't do it before the surgery, she could do it afterwards. Other patients want to reduce their narcotic intake. Other people want to return to sports and I've taken care of a number of professional athletes. Everyone has different goals.

And what I try to do is sit down with these patients and say, "Look everyone has a right to want to be completely pain-free, fully functional", but I try to be honest about, "Hey, this is where I can get you. I think that there's an 80% chance we can get you dramatically reduced and off narcotics and maybe another 15% chance it's controlled, but you have a little bit of pain." I'd always rather under promise and overdeliver, than to tell the patient, "Hey, I guarantee you'll be out of pain."

And everyone is going to be different after the surgery. As I alluded to earlier, when I was talking about you can do a surgery that the patient wakes up and immediately, they're fine. They even go home the same day. And then that night or the next night, they're in terrible pain. Or they're going to go through something where they're going to hurt for a few days and spend a few days in the hospital, but then their long-term outcome is really good.

And I'll talk openly with the patients. I'll say, "Hey, look, what are your goals?" A 75-year-old grandmother may not have the same goals of athletic activity and so on, On the other hand, I had an 87-year-old golfer who broke her neck and she wants to get back out on the golf course. So that was an important quality of life goal for her.

Everyone has different goals. And I think you need to sit with your surgeon and talk about what your personal goals are. And the surgeon's got to be open about, "Hey, look, in my experience, patients with this particular problem, you can reasonably expect this percent chance that you're going to be pain-free or at least pain-controlled."

Prakash Chandran: Yeah. I think that transparency and setting the expectation is really important. You know, just as we close here, there's going to be people listening to this that aren't in pain and they want to be proactive about, reducing the need for spine surgery in the future. What advice might you have for them?

Haroon Choudhri: There are a number of things that we can all do. Cigarettes and diabetes both cause significant compromise of the ligaments around the spine, so controlling diabetes if you have it, avoiding it if you can. And not smoking will do a lot to help you with your spine. Maintaining a good healthy weight and exercise regimen will both keep the muscles that support the spine and build your core muscles as well as not putting undue strain on your spine.

Now, some patients, they do heavy manual labor, and you can't fault people for that. Some people do a lot of exercise. Proper lifting technique something you can pay attention to. Bending at the knees instead of bending at the waist, making sure that you ask for help. A lot of nursing staff do tremendous amount of work with larger and larger patients. And oftentimes they're in such a rush that they don't have time to call for help and so on. Getting the help, making sure you're lifting things. Making sure you have a couple people helping you out when you're lifting something heavy, you can avoid unnecessary strain on your spine.

And you also have to listen to your body. Sometimes you have pain, take it easy. And, most of us, 80% of people will get spine problems at some point in their life, 95% of these will get better with eight weeks of bed rest or physical therapy, well, possibly some simple analgesics. So barring any warning signs of serious weakness or loss of control of your bowel and bladder, barring those, if you can try and take it easy for eight weeks, you're more likely than not going to get better.

Patients who don't get better or who have significant weakness in their legs or arms, or have difficulty with their bowel and bladder problems, those patients need to get checked out. And in that case, it's actually better to get checked sooner. You don't want to do surgery if a patient doesn't need it. However, you also don't want to wait until it's so bad that a much bigger surgery is needed or the chances of a good outcome have gone away. I think it's reasonable to see a spine specialist who works as part of a team. I send many patients for physical therapy or injections, or tell them to avoid spine surgery if they can avoid it, but every patient is an individual and you need someone who's going to consider all options and try and find what's the right for a given patient at a given time.

Prakash Chandran: Well, Dr. Choudhri, I think that is the perfect place to end. I really appreciate your insight today and I think it will be helpful for a lot of people. That's dr. Haroon Choudhri, a neurosurgeon at St. John's Riverside Hospital. Thanks for checking out this episode of Riverside Radio HealthCast.

To make an appointment with Dr. Choudhri, you can call (914) 233-9716. For more information on providers, visit RiversideHealth.org.

And if you found this podcast helpful, please share it on your social channels or check out the entire podcast library for topics of interest to you. This has been Riverside Radio HealthCast, a podcast from St. John's Riverside Hospital. Thanks and we'll talk next time.