Episode 20: Surgery, the ultimate placebo, with surgeon Prof Ian Harris for back pain fact 10
Low back pain is still the world’s most disabling health condition and costs more than cancer and diabetes combined. A scientific journal article covering 10 facts about low back pain was recently published in the British Journal of Sports Medicine (http://dx.doi.org/10.1136/bjsports-2019-101611). The origins and motivations for that paper, as well as patient stories, were covered in episodes 4 and 5 of the podcast. In this episode, Professor Peter O’Sullivan, Dr JP Caneiro and Kevin Wernli welcome Professor Ian Harris to the podcast to discuss low back pain fact number 10: injections, surgery and strong drugs usually aren’t a cure. Professor Ian Harris is an orthopaedic surgeon, a scientist and a self-proclaimed sceptic and just an all-round great guy! In this episode we discuss:
- The effectiveness (or not) of spinal surgery
- Why there is such vast differences in outcomes in patients under the worker’s compensation scheme
- Is pain all in your head?
- Alarming rates of increasing surgery rates in the private sector compared to practically no increase in the public sector, and why that might be.
- A call for better evidence (and who should fund it!)
- The key question patients NEED to ask their healthcare professionals.
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Episode Show Notes:
Professor Ian Harris: For most people in the public if you were to tell them that the surgery they were proposing to have, or this operation or that operation doesn’t actually work, it doesn’t sit right.
It doesn’t make any sense. Why would you do it if it didn’t work? So, I’m trying to make the public a little bit more sceptical, meaning not cynical, but meaning scientific and more objective and not just assuming that things work because people do them.
So the evidence for what we do as surgeons for musculoskeletal pain is very bad.
Kevin Wernli: That was professor Ian Harris. An orthopedic surgeon, scientist and author. And, this is the final episode of our first ever season of the “Empowered Beyond Pain” podcast. Proudly brought to you by Body Logic Physiotherapy.
Last episode we said we were going to go out with a bang, and if this episode doesn’t live up to that – then I’m not sure what will.
I consider myself extremely lucky to be in the fortunate position to give voice to the valuable stories from the people who have a lived experience of the conditions we discuss each episode. As well as talk to world-renowned and respected clinical researchers, to bring new evidence to your eardrums. The calibre of today’s guest is no exception.
We are so lucky that people like you tune in to each episode, and we hope we’re giving you value for your time with the knowledge that we’re translating.
Today, Professor Peter O’Sullivan, Doctor JP Canero and I speak to none other than professor Ian Harris. About all things surgery, placebo, research, and pain.
Ian is a clinician and researcher based in Sydney. He’s an orthopaedic surgeon with a clinical interest in trauma care, where his practice is based at Liverpool Hospital in Southwest Sydney.
He’s a professor of orthopaedic surgery at the Southwestern Sydney Clinical School at the University of New South Wales, Sydney. And an honorary professor at the School of Public Health, University of Sydney. Where his research is based at the Institute for Musculoskeletal Health.
His research interests are in surgical outcomes and the appropriateness of medical care. He conducts randomized trials, systematic reviews, cohort studies, and method studies, and has over 260 publications, receiving over 31 million in grant funding since 2012. He’s a critic of many aspects of modern medical practice and is a campaigner for more science in medicine and in society.
Ian has appeared on many national television programs, including a segment that ABC 730 has been kind enough to give us permission to use, which will play towards the end of this episode.
As always, relevant links including to that ABC segment, Ian’s book titled “Surgery the Ultimate Placebo,” the references from the scientific articles that we discuss in today’s episode, a transcript and much more are available at the show notes page. This can be found at www.bodylogic.physio/podcast
It was such a special chat that we shared with Ian and I hope you enjoy it too. It wouldn’t surprise me if you find yourself frequently skipping back to re-hear some of the knowledge that Ian drops. Just to make sure you understood it correctly – I know I will be!
We’ll start today’s episode with patient voice Steve, who actually features in that 730 Report, that will play towards the end of the episode. Steve will present fact 10 from the “10 facts every person should know about back pain” paper that we published in the British Journal of Sports Medicine.
Then, we’ll get straight into the chat with Ian. We wish you a fun and safe festive season and would like to thank you for your incredible support thus far. We encourage you to share your thoughts with us online at EBP podcast on the socials. Lave an iTunes review if you have a spare 20 seconds.
And, for the final time in this incredible year that has been 2020, remember to ask “is there more to pain than damage?”
Patient Steve: Injections, surgery and strong drugs are usually not a cure.
Male Host: Spine injections, surgery, and strong drugs like opioids usually aren’t very effective for persistent back pain in the long term. They come with risks and can have unhelpful side effects. So, finding low-risk ways to put you in control of your pain is the key.
To read the full paper for free, search “back pain facts BJSM”. If you’d like to watch the patient stories behind the facts, click the link in the description.
Male Host: So today on the podcast we have a very esteemed guest. Professor Ian Harris is an orthopaedic surgeon, a scientist, a sceptic, a Sydney sider, a salubrious human, and the author of this fantastic book titled “Surgery, the Ultimate Placebo” which I must say has probably caused a lot of stir in the medical, and the broader, world.
Ian, we’re so grateful you can join us today. Welcome to the podcast.
Professor Ian Harris: Thanks for having me.
Male Host: So, it’s pretty common for people with back pain, or any pain of that matter, to sort of, think that they need surgery. That surgery is going to be this, the most beneficial thing for them. And surgery is at the top of the medical triangle, I guess.
But, certainly, the vast majority, if not most people, with back pain probably won’t get any extra benefit from surgery than an alternative intervention like a structured cognitive and functional rehabilitation program.
And, I suppose, as an orthopaedic surgeon, and now prolific researcher, you’re probably one of the best people to ask about when surgery is appropriate.
But, before we dive into that, can you tell us a little bit about your story, please.
Professor Ian Harris: Yes, I’m an orthopaedic surgeon that trained locally in Sydney, did some stints overseas, and basically just set myself up as a trauma surgeon.
Mainly treating fractures, but I also treated backs and used to do back fusions, decompressions and things like that, as well as spine trauma.
But, then gradually got into the research side of it. I wasn’t real comfortable with the evidence for what I was doing, but I didn’t have the skills to know what good evidence and bad evidence was. And, I really couldn’t determine, you know, what I should be doing because I didn’t have the critical appraisal skills that I saw that others had.
So, in pursuing those skills, I ended up, sort of in, an academic career which parallels my sort of clinical practice. So, I’m still in clinical practice but I say these days I do most of my work is research.
But yeah, so that’s how I ended up where I am.
Male Host: So, if you look at your journey and across your career, and you look at what you were taught about back pain versus what you know now – how different are they?
Professor Ian Harris: Yeah, it’s completely different. And, it’s different with a lot of fields, but it’s probably most different in back pain. So, I was taught a lot.
To put in perspective, these days when surgeons want to do spine surgery they tend to just do spine surgery, so they’ll go off and they’ll do specialty fellowships.
When I did my training, everybody did spine surgery, and everybody did knee surgery, and everybody did shoulder surgery. So I saw a lot of spine surgery when I was doing my training and did a fair bit of it.
Male Host: Yeah.
Professor Ian Harris: And, I saw how to do fusions and saw the evolution of surgical techniques for fusion starting from no instrumentation – just putting the bone graft in there, to early instrumentation, to more modern techniques.
So, I saw all of that happen which was interesting. But, the thinking around who you operated on, was you just operated on people when non-operative treatment didn’t work.
You know, it’s this thing gets ingrained in you as a surgeon. It’s like if non-operative treatment doesn’t work…then you do surgery.
But then that doesn’t answer the question, does the surgery work? Because, if the surgery doesn’t work, the failure of non-operative treatment doesn’t make it any more effective. It still doesn’t work
But we didn’t ask those questions, and so we did all sorts of things. We put people who had back pain into a cast as a test to see whether a fusion would help them.
So if you put them in a cast and they said they felt better then we’d fuse their back. I mean it just made you know on the surface it makes some inkling of sense, but when you think about it for more than a few seconds it makes no sense at all.
But that were the kinds of things that we were doing, and so when I started to practice I would sometimes fuse people with back pain. Because that’s what was done
Male Host: So if you look at your research journey how has that changed your understanding of back pain?
Professor Ian Harris: Yeah. So, I guess I haven’t given you the rest of my “that’s where it started”.
So, that’s why I started the journey. And then once I started looking into the evidence for things and understanding, you know, how evidence is generated and how we can be certain about some things and not others.
I quickly started to realise that a lot of things that we do, and I mean, we’re picking on surgery at the moment, but I also realised that a lot of things we do in physio, in medicine in, everywhere, didn’t really have good evidence. And, a lot of it had actually been shown to be ineffective.
So that really was an eye-opener, and that’s one of the things that really swung me into research – and learning more and more about it.
And, really, the book kind of came out of my frustration with, kind of like, chipping away at the surgical, in the surgical field, and realising that most people in the community weren’t aware of these debates.
And so, I kind of wrote it. Looking to appeal to the public. Appeal to people in general, because, it’s probably changing now, but for most people in the public if you were to tell them that the surgery they were proposing to have, or this operation, or that operation doesn’t actually work – it doesn’t sit right.
It doesn’t make any sense. Like, why would you do it if it didn’t work?
Whereas people can quite understand that a pill might be ineffective. They can quite understand that, “I know those pills are useless”. You know, and even some other areas of specialty they might think “yeah that’s all pretty useless “.
But, they don’t understand the concept that if you go in, and mechanically change something and you fuse this bad segment together so that it’s not there anymore. How can that not work?
What insurgents would be doing it if it didn’t work? None of it made any sense, there’s all this cognitive dissonance. So, I’m trying to make the public a little bit more sceptical. Meaning not cynical, but meaning scientific and more objective, and not just assuming that things work because people do them.
Because that’s the way I was taught. I was taught that this is the way we treat this condition. Why? Because that’s the way we all treat it, and so it must be right. And, it’s only later you realise that the way that everyone’s treating it is wrong.
Male Host: Yeah, so if you look at the research work that you’ve done on the area of back pain, what does it tell us about the role of surgery in back pain?
Professor Ian Harris: I haven’t done that much in back pain but I did do a couple of reviews recently. And just in the last year or two a few of us published a paper looking at the evidence for spine fusion.
Which is, and just to maybe put it in perspective for most people, there’s lots of different operations you can do on the spine. And you can do some in the neck, and you can do some in the lower back, but the operations are largely broken up into decompression operations where you’re taking away pressure from around a nerve.
Or, fusion operations where you’re fusing two or more vertebrae together to make them solid. And, of course, you can do a fusion and decompression, but the spine fusion to me, is the biggest problem.
I think there’s still problems with decompression, but fusion is the one where I don’t think there’s a lot of good indications for it and it’s overdone.
So, we reviewed the evidence. We just looked at “where is the evidence?” What good evidence is there for fusing the the lumbar spine for various conditions?” And we found that there’s there’s very little evidence for it.
We did find some small areas where it’s possibly effective. So, for example, we did find a trial that compared spine fusion to not fusing patients who had metastases or secondary cancers in the back. And that often causes the back to be unstable and it can collapse and it can be painful, and can cause nerve problems and then difficulty getting around.
This study showed that if you operated on those people and fused their spine together they did a lot better. That’s quite believable. And it’s good that somebody did the trial because now we’re a little more certain that it’s, that it’s right.
That kind of surgery, you know, probably has a role. But, if you look at the proportion of spine fusions being done in the world that are for secondary cancers, it’s nothing. It’s, I would guess, it would be less than one percent, you know. It’s not a big number at all
Whereas the other thing we looked at is trauma, so fractures of the spine. So, again, there may be a role there when there’s quite a severe fracture and the spine is dislocated out of place.
However, for the most common fractures – which are not like that, they still get treated surgically, but the best evidence we have is that patients don’t do any better with surgery than they do without.
And the costs and complications are high with surgery. So, even though we’re kind of “oh your spine’s broken we’ll operate on it” which kind of makes sense, but no, it’s not that clear. And for the most common fractures I think surgery is probably not helpful, and then we come to the big ticket items which is degeneration.
Yes, it’s the, you know, all the different names for it. Disc disease, degenerative discs, arthritis, spondylosis. And commonly this is treated with back pain, it varies a lot between countries and between geographic regions within countries.
And when you see that degree of variation it normally tells you that there’s uncertainty. That we don’t really know what we should be doing because some people are doing it a lot and some people aren’t doing it at all so there’s something wrong there. But I think that’s an area where it is overdone.
It’s quite possible that there is no role for surgery for degenerative conditions in the spine for spine fusion. So this is bar in cases that of the one-off cases that happen to have a, you know, very unstable spine or something like that.
Most of them don’t need it.
There’s a tendency to find more and more reasons to do it. One of the flavors of the month is this sort of coronal plain instability and people who develop a little bit of collapse and they get a bit of scoliosis. And so people are doing fusions for that and in the old days we used to fuse two vertebrae together that’s called a single level fusion or a single disc fusion.
These days, they’re fusing people from top to tail. You know, they’re doing five levels, ten level fusions, which are massive operations normally in older people. I am not at all convinced of the evidence that the risks of that kind of surgery are justified by the benefits and there’s certainly been no good comparative studies showing that they are.
Male Host: Yeah.
Professor Ian Harris: I mean, I think that that’s what’s needed.
Male Host: Yeah, and I think you’ve done some research in the work comp, Workers Compensation space, as well looking at the outcomes of people who’ve had a lumber fusion if you’ve had a workers compensation injury.
Professor Ian Harris: Yeah, a lot of my early research and actually my part of my PhD thesis was on, I was fascinated by this compensation effect.
We didn’t get taught about it at medical school, but once you get into practice particularly as a surgeon you see lots of patients who are treated under Workers Compensation, and you soon realise that these are very different people.
Often there’s lots of psychosocial problems that are interfering with their recovery. You know, often they’re not happy at work or they’re having a conflict with their their boss or their employer. They’re often not motivated to go back to work, and they often have to go to see medical examiners to prove how well they are.
Otherwise, they don’t get a payment, a payout, and the payout depends on how sick they are. It’s a very, very bad system that’s rife with perverse incentives and there’s perverse incentives for the surgeons as well because the payments that we receive from the Workers Compensation system far outweigh the payments we get from the public system – or even from the private system.
It’s a very generous system for surgeons, and so I think that that’s a formula for disaster. So, it’s common to have spine surgery in Workers Compensation situations. And yet, we have shown, and others around the world have in other countries and jurisdictions, have shown that the outcomes are much worse after surgery if it’s performed in a Workers Compensation environment.
And, it’s partly for these psychosocial reasons, you know, it’s very difficult to make these people better. Particularly when the thing that’s causing their problem is not a structural physical problem.
If you give a structural physical solution to a psychosocial problem you’re not going to get a good result. And, so yeah, we did a meta-analysis on outcomes after different types of surgery. This was lumber fusion for instance, but also carpal tunnel syndrome, a bunch of other common shoulder surgery, common operations in the Workers Comp situation.
But, the odds of having an unsatisfactory outcome if you had that operation under a Workers Comp situation was somewhere between three and four. So, you know, three to four times the odds of a bad outcome.
You’re really setting yourself up for failure when you operate on these people, and yet it’s commonly done.
We’re just trying to publish some stuff on that now. We just looked at all the SIRA data, so in New South Wales the Workers Comp system now is managed under SIRA which is the State Insurance Regulatory Agency. And, so, we’ve got a whole lot of data from them looking at the rates of surgery and how they’re increasing and what the costs are and things like that. And the outcomes are still bad, and we previously published on this as well in Workers Company New South Wales
In fact, one of the numbers I remember from that publication was we looked at patients who had lumbar fusion. We had about 450 – 460 something patients, over a few years. We looked at how they were 24 months after the surgery. The probability of returning to pre-injury duties, after two years after spine fusion was 3%.
The probability of still being treated with either ongoing physiotherapy, or major opioids – narcotics, two years after your fusion was somewhere between 80 and 90 percent.
So these people did not get one bit better
Male Host: And so that’s kind of shocking isn’t it. It’s almost shocking to hear statistics like that and and I suppose the question then is, you’ve got a person who may be highly distressed around the whole work comp space. Which could, you know, like navigating that in itself is incredibly stressful I reckon.
And then you had all the work related issues, and then the, you know, dealing with legal factors etc. And it tells us a little bit about the complexity of back pain. That it’s a lot more to do than other factors, in some cases. than just structure. But that’s a really hard message for someone who has pain to hear.
Professor Ian Harris: Exactly, and I’d have to manage that all the time and you guys have to manage that as well. It’s very difficult. I’ve honed it over the years but it’s not a message you can get across in a single consultation
You know, people have to be believed, and one of the things that I stress with people is – I do not question in any way the fact that they’re having pain. You know I can 100% believe they have pain.
But what I try to get across to them is that their perception of the pain, the way they react to the pain and their response to the pain, and the whole sort of, you know, psychological picture around their behaviour because of this pain is strongly influenced by many different factors.
And yes, it’s quite possible there was a physical problem that may even have initiated their pain in the back. But when these other things take over they they take over your brain subconsciously. You know there’s the old ways of thinking about pain, you know they turn up the volume on your pain and that kind of thing.
And so, I try to do in my role because I’m not a chronic pain specialist or a rehab person or anything like that. They often come to see me for an opinion regarding surgery and these days, because I don’t do that surgery anymore, they often get to see me for a second opinion because they’ve been advised to have surgery.
So I see lots of patients like that, and so all I try to do is just, get them to think that this is perhaps a little bit more complicated than they thought. And there’s lots of other factors that are contributing to their current unpleasant experience. Which is, you know, being expressed by back pain, and frustration, and anxiety, and all the other things that they’re feeling.
But, just to get them thinking that it may be a little bit more complicated than that, and then you have to address the physical, the inevitable physical problems, because the patient will always turn up with an MRI scan.
Every MRI scan will show an abnormality, so you have to explain to them that the findings that I see on their back are no different than I would see in in any other, you know, 45 year old or 55 year old or whoever old they are. And that those signs are not well correlated with pain
There are plenty of people with those exact signs who don’t have any pain, so again, it’s not that simple thing.
Humans love shortcuts, you know, where we’ve evolved to make these heuristic u conclusion jumps. As soon as we see something, and we see something that goes along with it, we just put the two together and say that one caused the other
So as soon as we see something on the MRI regardless of what the evidence tells us, and we’ve got someone with back pain, and we say “well whatever it is I can see on the MRI – that’s causing your back pain. So I’m going to take it out.”
It’s very appealing. It’s very easy to understand. Patients can just stop thinking right there, and just say, “OK, take it out. I’m done.” That’s “you’ll cure me”. So telling people that isn’t that simple, is hard work.
Male Host: And how, what kind of response do you get? Because obviously they’re coming to you as a for a second opinion. You know you’re an orthopaedic surgeon, you’re looking at them, hearing their stories, and looking at their scan. And then in a sense you’re not validating this scan.
How do people respond to that?
Professor Ian Harris: it’s completely varied. I mean, I get all into this spectrum and everything in between.
So certainly I get the people, that you know, the initial response is “you’re telling me it’s all in my head.” And, yeah you don’t. And you know, I don’t know if it’s a good response or not, but when people say “you know you’re telling me it’s all in your head”, I tell them all pain is felt in the head.
That’s that’s where pain is registered. And I tell them I have people that have no leg but have foot pain. It’s not because they have pain in their foot they have pain in their head. That’s where they’re registering it, that’s where it all gets controlled.
And so I use that as a stepping stone to to explain a little bit further. But sometimes people are just very frustrated and you you can’t get through to them.
That’s not that often, and it’s also not that often I get the other end of the spectrum because quite a lot of people, I think, don’t really want to have surgery.
So they’re fairly relieved, or happy to know that they don’t need to have surgery at least.
Then, there’s the question “well what am I supposed to do instead?” You know, that’s, yeah, that’s difficult.
You have that conversation, but some people are relieved and, particularly, maybe it depends on who they’ve come from. Because spine surgeons, I’ve got a lot of friends who are spine surgeons and, you know, most of the spine surgeons I know are entirely reasonable. You know, intelligent, good surgeons, who care a lot about their patients and don’t take these things willy-nilly.
But, there are surgeons out there that are reasonably aggressive and sometimes patients feel as if they’ve been pushed into surgery a little bit. And they’re not sure that it’s really needed and sometimes they’re happy for and out .
You know, even if it’s that, I can’t do very much to help them except tell them that surgery will possibly make them worse. Sometimes they’re happy with that.
Male Host: So how do you get on with this messaging with your colleagues because, clearly, I don’t know what the numbers are for lumber fusions in Australia, but I imagine that it’s pretty huge.And, particularly in the private and work comp space, am I right? compared to the public setting?
Professor Ian Harris: Yeah, so we’re looking at this now, looking at the numbers, and it’s been very difficult to interpret because the rates of spine fusion have increased since 2015. I think so, the last four or five years, but there was a fall before then.
For a few years, I think, from 2011 to 2015, we can’t really quite work out why that is or whether that’s a glitch in the reporting, because coding numbers change and things like that. But we’re still working our way through that.
We are trying to compare the rates in public, versus private, versus Workers Comp because I think the rates in Workers Comp, I think, that’s often where it’s overdone. But it’s difficult because in Workers Comp you only have a select portion of the population.
It’s not the denominator, isn’t everyone in New South Wales or whatever, and they’re younger people. The rates of spine surgery across the board are much more common in people over 60. So it’s people who are 60s, 70s, that are getting surgery.
I think if you look at the rates of surgery of people in their 40s and 50s, then you do see that workers probably is a little high. But overall, per person, they’re not that high. Because outside the Workers Comp situation not that many people in their 40s and 50s get surgery compared to 60s and 70s, anyway, it’s complicated. It’s hard to work out.
We did do a study a while back where we looked at the rates simply comparing private versus public and found that the rates were increasing. Verry high in the private sector, and very low, and not increasing at all in the public sector.
And we compared that to hip and knee replacements. Where both hip replacements, and knee replacements were increasing and they have been for many years. But they’re increasing in the private sector and they’re increasing in the public sector.
I mean there’s a reasonably big demand for hip and knee replacements. And so they parallel each other, and sometimes it goes up and down but but certainly we’re doing much more in the public sector now than we were 10 – 20 years ago, and we’re doing a lot more in the private sector than we were 10 – 20 years ago
The funny thing about spine fusion surgery is that it’s been going up and up in the private sector but it’s still not largely, not done much.
Male Host: Why do you think that is?
Professor Ian Harris: I think that, I would guess, that reason is because we don’t really know that it’s that effective. So we’re fairly sure that someone who has difficulty walking with a very bad arthritic hip will do better, you know, 95% of the time and will be able to walk freer, improve their mobility, and and decrease their pain possibly to nothing.
So when someone comes in and sees us with a bad arthritic hip, in terrible pain and can’t sleep and can’t walk around – go get a hip replacement. It doesn’t matter whether public or private because we know it’s an effective operation.
I think it’s different if someone comes into you with back pain and they’ve got, you know, degenerative changes or whatever and that fails the course of physio or something. And they’re not coping very well, you could probably spin it either way.
So, if I was a surgeon I could easily say to a public patient for which I’m not going to get much out of it by operating on them, I could easily say,
“Look you’ve got this problem, but this problem isn’t really correlated with the findings on the scans, there’s lots of complex reasons why you have pain. The best evidence we have is that surgery will probably not help you.”
That you know there isn’t really very good evidence supporting it at all. So I wouldn’t recommend we do such a a dangerous procedure for a little gain. You know, and I would advise against surgery.
Think of a private patient, or a Workers Comp patient sitting in front of me. I could have almost the same conversation.
So, I could say, “well look, you know the evidence for spine surgery is very good and some people do better, some people don’t. You know, we really don’t know. There’s a lot of controversy out there about spine surgery, but we really won’t know whether you’re the right person for it whether you’ll respond to it and until we try it. And you failed everything else so I can’t really see you getting better without it. So I think it’s worth a go. You know, we’ll do a fusion we’ll see how you go.”
Yeah, it’s the same conversation but with a different outcome.
Male Host: Different bias, and so what do you say then? And this kind of gets to the title of your book around surgeons who said like, “I have great outcomes from doing spinal fusions for people with back pain”. And patients who say “look I had that surgery done and you know it’s changed my life.”
How do you respond to that?”
Professor Ian Harris: Yeah well, for every one of them I think tthere’s a patient who says they regretted having the surgery. But, yeah, so that you’re getting to really the core of the book, which is this problem. The answer to the question of why do surgeons do operations that I think are not effective based on the evidence?
And, I’m fairly convinced that the reason why surgeons do these operations is not because they want to make extra money, and it’s not because they’re tapping into a placebo response or anything like that.
It’s because they honestly believe that it works.
The reason why they believe it works is because they see people get better. Now they may quite selectively see people get better. And they might see those people through rose-colored glasses, and they might not ask those people all the right questions. They might not see them for very long.
And that patient may be giving that surgeon a very different answer than they’re giving their physio, or their GP.
But, they see people get better. And they fall into the logical trap of attributing that improvement to the surgery. When that’s probably not the case.
And it’s the same argument I have for, you know, debridement of osteoarthritis in the knee, knee arthroscopy for degenerative changes, and things like that. Is that, the improvement you see is probably less than you think. And where it exists, it is probably not attributable to your surgery, it is attributable to other more common things like the natural history and fluctuations of conditions.
Shoulder surgery, I think, is a classic for that one as well, because I just recently went through in the last, say, four or five years, I went through two long term pain problems.
The first one was tennis elbow, and there are surgeons out there that will operate on that but we know statistically that 97% of people with tennis elbow will be all better in 12 months.
Because that’s the natural history of the disease
So, if you operate on people and you look at your results at 12 months you’re going to think your operation has a 97% success rate. You know, and you’ll believe it. But it’s a true belief. The other analogy I give is that it’s like homeopaths. Homeopathic is classic because homeopath, homeopathy, is true, nothing like that.
It’s a blank treatment, you know, you’re giving water in small amounts so it’s nothing. And yet, there’s a lot of homeopaths out there and they’re giving a lot of homeopathic treatment. I don’t believe that these people are charlatans, I believe that the homeopaths believe that what they do works because they see people get better and they attribute that improvement to their treatment. Instead of to the natural history of the of the condition.
The other thing I had was a bad shoulder. I didn’t even have it scanned I didn’t know what it was but couldn’t lift it for ages. Couldn’t reach me on my back, I was using my other arm. I couldn’t reach over to the back seat of the car, yeah, terrible problems.
And I just had to, like, keep it still a lot and didn’t bother having scans. Didn’t do anything, it took about a year. Now it’s 100% again, it’s completely normal so…
Male Host: Such a hard thing for patients to accept though, when they’re distressed isn’t it? So yeah, because of your knowledge you can deal with your own health problems in a completely different way.
The patient who has a problem, gets a scan, shows a rotator cuff tear which we know are really common, and often people have no pain at all. That gives them a simple explanation to why they hurt, then they believe they need to fix it.
Professor Ian Harris: Yeah, yeah, so you just got to educate them.
I mean, you know it depends on the condition, but you guys probably know the figures more than me, but most people with shoulder pain will will be better in 12 months.
Male Host: And I suppose the tricky thing there Ian is, for the people we know with back pain, we know around 25% won’t get better from an episode of back pain.
And that’s the really tough thing because if we look at the five or seven year trajectories of that group, they don’t tend to look good.
Professor Ian Harris: It’s not good.
Male Host: But that’s what’s so tough about this whole conversation. It’ss like, well, if I’ve tried all the stuff and I haven’t got better, and I’ve got a degenerate disc on a scan. And maybe someone stuck a needle, and it gave me short-term pain relief that proves that that’s the cause of my pain, and therefore this is my only option.
Professor Ian Harris: Yeah.
Male Host: It’s so compelling.
Professor Ian Harris: But you’ve basically outlined the the argument of a lot of reasonable surgeons. Yeah, they would make that argument. But it is largely based on their personal experience and some not very good evidence. I think we need better evidence to find out if it works. Instead of us all guessing.
Male Host: Yeah.
Professor Ian Harris: We should be doing the studies, and this is another big frustration of mine is that we we think up these these things. We do them, we think up a new spine operation, we start doing it. We think it works. Nobody tests it
You know, shouldn’t we be testing it before we do it?
Male Host: Drugs aren’t allowed to be put out of the market before you test them, why is surgery?
Professor Ian Harris: Yeah, isn’t that just a basic principle of learning and science is to find out if things work first and then try them? Instead of what we did with the arthroscopy. We started doing it in the 70s and 80s, and in 2013 we published a trial showing it doesn’t work. Shouldn’t that trial have been done in 1980? I don’t know.
Male Host: It’s hugely concerning though, because consumers put so much trust in the health system.
Professor Ian Harris: Yeah, but we abuse that trust. We know, and you know, if the surgeon says you need this it’s pretty hard to talk people out of it because it’s a very authoritative voice in society.
That often, you know, doesn’t often get questioned, and because it doesn’t often get questioned, I think it gets abused.
You can just say no. In my experience, you know, you’re far better off having this procedure and you don’t have to justify yourself you don’t have to produce the evidence. You don’t have to submit a document to the therapeutic goods association. Or the medical benefits schedule of Australia to prove that it works.
Male Host: Do you see that culture changing with young surgeons coming through?
Professor Ian Harris: Yes, I definitely think that the young student is a different breed to to older surgeons, for sure, yeah. Things are changing but I think the change really shouldn’t be generational in nature. It should be a little faster than
Male Host: But I’m aware that, you know, I think one of the wiser initiatives suggested that public funding shouldn’t be used but for spine surgery and that got rolled. Because it was an outcry, and so funding’s been kind of reinstated.
Professor Ian Harris: Yeah, this is the problem, is that spine fusion along with most of the other operations on the funding list in Australia were grandfathered in.
I mean, they were operations that were already being done in 1983 or whenever it was when the MBS was was written in 1985. And that was it, so they’re all grandfathered in. If you wanted to do a new operation today and get it funded by the government you’d need a considerable amount of evidence before they would do that.
So, my argument is that OK, it’s a big task, we need to go back through all of those things we’re funding and evaluate them the same way as we would with any new procedure that was presented today. I would even argue that we need to use the public money for that.
Medicare in Australia pays, you know, billions and billions of dollars for procedures being done. They should put a little bit aside, you know, two cents in the dollar or something like that for comparative effectiveness studies or trials finding out whether the things they’re paying for work. They only need to show a couple of things don’t work and then they can save themselves millions of dollars a year.
You know, I think that that’s something that needs to be done. We shouldn’t be doing these things without evidence. It just sounds basic, but yeah.
Male Host: That’s consistent with the most recent guidelines for back pain, is that, I think, the guidelines said spinal surgery should only be used as part of a research trial.
Professor Ian Harris: Yeah.
Male Host: But we ignore the guidelines don’t we?
Professor Ian Harris: But it’s a very compelling case to say that. And I say this to surgeons as well. They say, “oh well, if you want to test everything, you’re going to stymie innovation.” Yeah, you know, because I’ve got a new procedure I want to do, and if I’m going to have to subject it to all your testing then all these patients will miss out.
And my answer is what you just said. I say, “no do it. Do it as much as you want, but do it as part of a trial.” And then we’ll know if it works or not, and you won’t have to waste your time doing it anymore if it doesn’t work. If it does work, let’s go to the government, get this thing reimbursed, and you can all get paid to do it.
The government would be more than happy to pay it because they know it’s effective
Male Host: Yeah it should work. So, some of the listeners to this will be kind of shocked, I would think, by what you’re saying. But the other thing that you highlighted is a whole risk benefit thing and that tsurgery is not without risk.
Can you just talk through what kind of risk might be involved with something like a spinal fusion ?
Professor Ian Harris: Yeah, so a spinal fusion is fairly major surgery. It’s another reason why it’s more of a target from me than decompression surgery because it’s a much bigger operation. It’s a longer time under anesthetic. It’s more invasive, there’s more cutting of the bone, and drilling and things like that. There’s insertion of devices like screws and plates and rods to hold things together.
And so, the risks, the complications that can occur after spine fusion surgery are higher than after simple decompression surgery or an arthroscopic surgery. For example, a shoulder arthroscopy or knee arthroscopy – it’s fairly safe surgery. It’s done day only, the patient really doesn’t bleed at all.
They don’t need to stay in hospital, they can walk out of hospital and the risk of infection which we often worry about in surgeries, is extremely low
You know. most of the risks of arthroscopic surgery are well below 1%. So they’re there, but they’re very low. But spine fusion surgery is a different story. You’re very close to the nerve so you can have damage to to the nerves.
And sometimes some of the screws you put in cannot go in the direction they’re meant to go. Uou can get bad bleeding, and probably the biggest complications of spine surgery is that it won’t work. You’ll still have pain afterwards but it can also cause more problems with the joints next to where you fused. So they take more stress and that can cause problems.
Often things come loose or they get infected, or they’re sticking out a little bit, or they’re rubbing, and all the fusion doesn’t take and it needs to be redone. So the revision operation percent is very high and that alone I think is is not a good sign. We do have some recent numbers for that.
If you look at, say, hip or knee replacement, that’s like super common surgery. Everybody knows somebody whose had a hip or knee replacement. The risk of needing another operation within a year or two is pretty low. It’s maybe one or two percent, you know, that you might need to to have something adjusted or taken out. Or, you could get an infection you know, it’s one percent.
But it’s a couple of percent, and you need to take that into account. Once you get over that, the redo rate actually flattens out quite a lot and the chance of needing another operation even after, sort of, ten years is only, sort of, four percent. You know it’s very low.
Spine fusion in the recent Workers Comp data that we did, we found that the re-operation rate within two years to have another spine operation was 19%. So that’s nearly one in five people having another operation on their back within two years of having the first fusion on their back. Which means that in itself tells you this is not a great operation
Male Host: Yeah, yeah, and you know, the fact that we actually have a name for it, fail back syndrome, yeah she’s kind of shocking. But I don’t know if any other authentic procedures got that name has it?
Professor Ian Harris: No, no, no, surgeons don’t like that name.
Male Host: So I’m very aware that there’s reasons twe could use way more of your time. This is such an interesting and important conversation. Anything you guys want to kind of add? Because I feel like we probably have to wrap this up.
Alternate Male Host: Probably a question that I’d like to ask you, is what would you tell consumers, what conversation should they have with clinicians when it comes to surgery? What are the key questions they should be asking?
Professor Ian Harris: Yeah, that’s a very good question that I often get asked. What I normally advise patients to do is to do exactly what I do. When I am the patient, or my parents or relatives of patients, is – I just say to the patient, to say to the surgeon or the doctor, what is the evidence that having this procedure will be better for me than not having the procedure?
Because that’s really boiling it down to nuts and bolts. It’s having the procedure compared to not having the procedure. I’ve asked that question to a surgeon from another specialty once during a family consultation and he reacted.
Oh what are you talking about? So “you don’t know” is the answer. He really didn’t know. He’s just saying how safe it was in his hands and how his complication rate was low. And that’s all great, but I said, but what’s the probability of getting a good outcome with the surgery compared to not doing it?
It’s the most basic, counterfactual way of thinking. And that’s a lot of the reviews I did, we just did a review published in “Pain”, which you can look up because I really like it, it’s a good one.
But the journal is “Pain” and it was published, I think, just this year. And it’s a review of surgery for musculoskeletal pain, and so it’s back fusion, it’s osteoarthritis, it’s shoulder surgery, it’s carpal tunnel it’s osteotomies, ankle surgery. All the most common procedures we do for pain and what’s the evidence for them.
And we looked at all the randomized trials that were done, and less than one percent of all the randomized trials of these musculoskeletal procedures compared the procedure to not doing the procedure.
So most of the research we churn out in orthopedics is looking at different ways of doing a spine fusion, or looking at how good my results are. But it’s not comparing it to not doing it, and in most of the studies in all except one condition, the majority of trials that compared the procedure to not doing the procedure were not in favor of the procedure.
The evidence for what we do as surgeons for musculoskeletal pain is very bad.
Male host: I suppose I have one sort of final question then. And look, excuse me, we’ll highlight that study in the show notes of the podcast as well. We’ll give a link to it.
What does the future hold for us? You talked about some initiatives and some changes that you you’d make. Where are the wins going to come from in the future? What’s the future for you and what’s this landscape going to look like?
Professor Ian Harris: Yeah, so, we need to change practice, and changing practice is a whole special area of research almost.
And it’s, I think, it’s got to be multi-pronged. So one of my things has been to teach surgeons, so during surgeon training now you have to learn more about evidence-based medicine and things like that.
It’s training surgeons to be more scientific, training the public to be more scientific, and objective and sceptical and asking the right questions as well. And then there’s other levers which I haven’t ever really pursued, but I’m more and more thinking that they should be used. And that’s the external regulatory financial levers.
People are paying for this. And that’s what gets me, is that I’m paying for it, so I’m a little bit, you know happy for doctors to do what they think is best, you know. But what I say is that I don’t want to pay for it.
So if you want to go doing the arthroscopies on every patient, you see, and the patient believes, that what you say is going to work. There’s a little bit of buyer beware in there. It’s a little bit like I can’t control everybody, you know, there’s going to be people who do this. You know, knock yourself out, but I’m not going to pay for it.
I mean the governments not going to pay for it because I’m paying taxes. I’m paying a Medicare levy. I pay private health insurance, I don’t want them to pay for it. I pay Workers Comp premiums, and I don’t want them to pay for it.
So, I think there’s certainly a thinking, most people know, particularly in the private industry, it’s in government as well, but in in private health industry and in Workers Cmpensation settings, that they’re not getting value for money. And they maybe need to rethink how they allocate money, and should they be rewarding spine fusions with surgeon fees of twenty to thirty thousand dollars per procedure.
Is that a good use of their money? Yeah, I would argue that it’s not
Male Host: Yeah, that’s great thank you so much for your generous time. I did suggest 30 minutes, I think we’ve almost doubled it (laughs). Probably could have gone for a couple hours but actually we’ve got to let you go. We really really value this, and I know our listeners will really value this conversation.
You know it takes a lot of guts, I think, to do what you’ve done in your career. It takes a lot for a person to shift, and you know, we see people like Gordon Waddell and others, who have shifted across their career. I think it’s a huge testament to you as a person, and as a healthcare practitioner.
That you’ve done that and we’re grateful for it. So thanks so much, and I hope you have a wonderful Christmas.
Professor Ian Harris: Thank you, and thanks everyone.
Kevin Wernli: Thanks man. Thank you. Wow, what an unbelievable conversation that was. Ian’s knowledge humility and kindness really shines. There are two things that I want to clarify for our listeners. I think this was pretty clear in the conversation but I want to make it crystal clear.
First, pain from psychosocial reasons or having a psychosocial problem does not mean the pain isn’t real, made up, imaginary, or exaggerated.
As Ian pointed out, pain is always real. Whatever people report is 100% what they feel, and there is a bit of a problem out there where patients don’t feel validated, heard and feel like they have to prove that they have a problem to their healthcare practitioners
It can be pretty hard to improve your pain problem, when at the same time you’re fighting to prove you have pain. So pain from psychosocial reasons just means that there isn’t a structural problem in the back that is contributing to the pain. Which is actually a good thing.
It does mean the way that people think, feel. or respond to their pain or the social environment they live in are more dominant contributors to their pain. Second, we don’t think healthcare professionals including surgeons, homeopaths, physios, chiropractor,s and so on that perform treatments that don’t work are charlatans.
The overwhelming majority are good humans who genuinely think that what they’re doing works. Because they’ve seen people get better. But what we’re asking you to consider is the “why” behind that improvement. As Ian talks about commonly, it’s natural history, or it may be other phenomena contextual effects like regression. A feeling of being listened to, looked after, cared for, having a condition made sense of or a feeling of safety.
OK, so there are a few, well a lot of question marks around surgery. But, that doesn’t mean all hope is lost, and we should wallow in our question marks, and there is nothing you can do if you’re considering, or have had, surgery.
The truth is, because there are lots of contributors to pain, it also means there are a lot of potential targets, and I want to highlight a story of hope. Enter back pain patient Steve who presented the back pain fact early this episode.
Steve first appeared on a radio interview that Professor Peter O’Sullivan did back in 2018. Serendipitously, he was listening and decided to call in to share his story and desperation.
Steve had a six year history of back pain. Was battling in the Workers Compensation space, was unable to work, had several surgeries, and eventually also had a spinal fusion that unfortunately didn’t really help.
He was one of the 97% of Workers Compensation patients that don’t return to pre-injury work within 24 months of a spinal fusion. And was most certainly one of the 80 to 90 percent that are on strong opioids and still require requiring ongoing treatment.
To cut a long story short, he was eligible for a study that was run through Curtin University, where he received a novel three-month intensive structured physiotherapy program and as you hear he underwent a huge transformation and is back to playing hockey.
He was back to working within that three month treatment, and now has a new lease on life. That study was my PhD study, and part of it has been published in the European Journal of Pain. There’s a link to a video abstract of that study the study itself in the show notes.
So I’ll now play the interview of when Steve called Gillian O’Shaughnessy from ABC back in 2018, and then i’ll play the clip from ABC 730 program which talks about his journey. And, a huge thanks to ABC for granting us permission to use these clips for educational purposes.
Gillian O’Shaughnessy: Steve is in Padbury. Steve is 24 and he’s had a spinal fusion. Hi Steve.
Steve: Hello, how are you?
Gillian O’Shaughnessy: Yeah, well thank you.
Steve: That’s good. Yeah, like you said, you actually told the wrong age. I’m 26 and I’ve had a problem since I was 21 with chronic pain. I obtained an injury at work
I’ve had two decompressions of the discs at L45, and then last year I received a single level spinal fusion. I’ve been to a lot of different sort of specialists and the main thing that they’ve told me is what you’ve been saying. Is going to the pool, and you know, just keep keep moving. But the pain is just really, really immense my body gets really tired really quickl. I find that I sleep quite quite a lot.
If I’m not moving a lot, yeah, but I find that just doing physical activity really, really makes you tired, wears you out and it’s just hard mentally trying to get over that hurdle.
It’s not only physical pain that you experience when you’ve got chronic pain and also the the mental pain that comes with it as well. Yeah, my questions about the medication.
I’m actually on, I’m not on any opioids, am I allowed to say the the type of drug I’m on?
Gillian O’Shaughnessy: Yeah, yeah, go ahead, OK.
Steve: So I’m on Norspan, I’m on Palexia, Tramado, and an antidepressant of Pristiq. Do you think that these drugs will do any benefit for me with with my chronic pain?
Kevin Wernli: So, as you can hear, Steve was in a pretty bad place physically and mentally. But, as I mentioned, he went through a bit of a journey and has had a huge turnaround.
in fact, he messaged me this week saying he got a best on ground at his hockey grand final and he’s doing talks with local schools about positive thinking and over overcoming obstacles with pain and injuries.
So, he really has progressed and is doing amazing advocacy work. In the next clip which is a report by Tracy Bowden from ABC 730, you’ll hear today’s guest Ian Harris talking about spinal fusion. And then again, you’ll hear from Steve talking about his journey.
Tracy Bowden: In 2017-18 close to 18,000 fusions were carried out in Australia. It’s one of the most common forms of surgery for chronic back pain. But there’s a growing debate about where the surgery is the best way to treat most back problems.
Professor Ian Harris: It’s a low level of evidence that we accept, and I don’t think that’s good enough. Particularly for highly invasive, risky, and costly procedures like spine fusion.
Steve: That whole time that I did have back pain I was looking for that quick fix.
Tracy Bowden: Steve is back at hockey training after a tough few years. He hurt his back working on a building site.
Steve: My back was seizing up and it was quite scary. I wouldn’t be able to walk without my leg dragging behind me.
Tracy Bowden: In the end Steve had three operations. The final one, a spinal fusion, I’m feeling no relief from these operations. Steve says a six-month physiotherapy program achieved what surgery couldn’t, treating his back pain and helping him return to sport and work
Steve: If I had my time again and doing this whole process. I would definitely explore other options and getting surgery to start off with.
Kevin Wernli: So there you have it, our final episode of the inaugural season of the Empowered Beyond Pain Podcast. I’d like to thank Body Logic Physiotherapy for their support in bringing you this podcast free of charge every fortnight.
My co-hosts Pete and JP, and all of our guests that we’ve been privileged to speak to this season. But, most of all I’d like to thank you the listeners. Each episode sees thousands of you tune in from more than 80 countries around the world.
So, it’s been a real honor to share these last few months with you. I wish you all the best over the festive season. Have a fun time and do get in contact with what you think the podcast sharing, rating, reviewing, subscribing are all easy and free ways you can help us help more people.
Do get in contact via EBP podcast on social media, or flick us an email with feedback, topic suggestions, or just a good day via our email which is email@example.com.
That’s it from us! Remember to hug your loved ones, and of course remember to ask, “is there more to pain than damage?”
Please note what you heard on this episode of Empowered Beyond Pain is strictly for information purposes only, and does not substitute personalized, high-value care from a licensed and trusted healthcare practitioner.
We are all individuals and need to be assessed and managed as such.
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