Episode 20: Surgery, the ultimate placebo, with surgeon Prof Ian Harris for back pain fact 10

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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:

O’Sullivan PBCaneiro JO’Sullivan K, et al
Back to basics: 10 facts every person should know about back pain
low back pain infographic
The video from ABC 730 program:
NICE Guidelines:
HarrisIan A.a,b,*; Sidhu, Verindera; Mittal, Rajata; Adie, Sama,c Surgery for chronic musculoskeletal pain: the question of evidence, PAIN: September 2020 – Volume 161 – Issue – p S95-S103 doi: 10.1097/j.pain.0000000000001881
Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: a meta-analysis. JAMA. 2005 Apr 6;293(13):1644-52. doi: 10.1001/jama.293.13.1644. PMID: 15811984.
Harris IA, Young JM, Rae H, Jalaludin BB, Solomon MJ. Predictors of general health after major trauma. J Trauma. 2008 Apr;64(4):969-74. doi: 10.1097/01.ta.0000245972.83948.1a. PMID: 18404063.
Ian A. Harris, Anita M. Harris, Justine M. Naylor, Sam Adie, Rajat Mittal, Alan T. Dao. Discordance Between Patient and Surgeon Satisfaction After Total Joint Arthroplasty, The Journal of Arthroplasty, Volume 28, Issue 5, 2013, Pages 722-727, ISSN 0883-5403,
https://doi.org/10.1016/j.arth.2012.07.044
Murgatroyd DF, Casey PP, Cameron ID, Harris IA. The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review. PLoS One. 2015 Feb 13;10(2):e0117597. doi: 10.1371/journal.pone.0117597. PMID: 25680118; PMCID: PMC4334545.
Kongsted, A., Kent, P., Axen, I., Downie, A. S., & Dunn, K. M. (2016). What have we learned from ten years of trajectory research in low back pain?. BMC musculoskeletal disorders17, 220. https://doi.org/10.1186/s12891-016-1071-2
Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL; Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013 Dec 26;369(26):2515-24. doi: 10.1056/NEJMoa1305189. PMID: 24369076.
The study Steve from the ABC 730 report was in:
Wernli, KO’Sullivan, PSmith, ACampbell, AKent, PMovement, posture and low back pain. How do they relate? A replicated single‐case design in 12 people with persistent, disabling low back painEur J Pain2020241831– 1849https://doi.org/10.1002/ejp.1631

Transcript

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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 what yeah why would you do it if it didn’t work so I’m trying to make the public a little bit more uh 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 that was professor Ian Harris an orthopaedic 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 well 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 and 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 dr jp canero and I speak to none other than the 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 which can be found at www.bodylogic.physio forward slash 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 7 30 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 would like to thank you for your incredible support thus far encourage you to share your thoughts with us online at ebp podcast on the socials leave 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

 

injections surgery and strong drugs are usually not a cure 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 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 I suppose um and we’re so grateful you can join us today welcome to the podcast thanks for having me 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 surgeries 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 yes I’m an orthopaedic surgeon that trained in locally in Sydney did some stints overseas and basically just set myself up as a 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 um but then gradually got into the research side of it 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 um you know what I should be doing because I didn’t have the critical appraisal skills that I saw that others had so in 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 so if you look at your journey in across your career and you look at what you were taught about back pain versus what you know now how different are they 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 I mean I worked under um 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 um 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 yeah and um I saw how to do fusions and saw the evolution of surgical techniques for fusion starting from no instrumentation just putting bone graft in there to early instrumentation to more modern techniques so I saw all of that happen which was interesting but the the thinking around who you operate was you just operated on people when non-operative treatment didn’t work you know it’s it’s the this thing gets ingrained in you as a as a surgeon it’s like um if non-operative treatment doesn’t work then then you do surgery um 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 uh so yeah we did all sorts of things yeah 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 um when I started practice I I would um sometimes fuse people with with uh back pain because that’s that’s what was done so if you look at your research journey how has that changed your understanding of back pain yeah so I guess I haven’t given you the rest of my that’s where it started so so that’s why I started the journey and then once I started looking into the evidence for things and understanding um you know how evidence is generated and how we can be certain about some things and not others I quickly started to realize that a lot of things that we do and I mean we’re picking on surgery at the moment but I also realized that a lot of things we do in in in physio in medicine in uh everywhere didn’t really have good evidence and a lot of it had actually been shown to be ineffective and so that really was a was an eye-opener and that’s one of the things that really swung me into research and learning more and more about it um and really the the book kind of came out of my frustration with with kind of like chipping away at the surgical um in the surgical field and realizing 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 what yeah 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 that uh I know those pills are useless um uh you know and even some other um uh 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 know fuse this bad segment together so that it’s not there anymore um how can that not work what insurgents wouldn’t be doing it if it didn’t work none of it made any sense there’s all this cognitive dissonance um so I’m trying to make the public a little bit more uh 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 realize that the way that everyone’s treating it is wrong yeah so if you look at the research work that you’ve done on the area of back pain what how do what what does it tell us about the role of surgery in back um I haven’t done that much in back pain but I did do a couple of reviews uh 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 um and of course you can do a fusion and decompression but but they’re they’re roughly but the spine fusion to me which 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 so we just looked at where is the evidence what 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 it’s possibly effective so for example we did find a trial that compared spine fusion to no few 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 and 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 and that kind of surgery um 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 it’s nothing it’s it’s I would guess it would be less than one percent you know it’s not a big number at all whereas uh and the other thing we looked at is uh trauma so fractures of the spine so uh 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 that we’re kind of oh your spine’s broken we’ll operate on it what kind of makes sense 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 um uh degeneration yes it’s the uh you know all the different names for it uh disc disease degenerative discs arthritis spondylosis

 

and commonly this is treated with back pain it 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 and there’s a tendency to to find more and more reasons to do it uh one of the flavors of the month is 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 and 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 yeah I mean I think that that’s what’s needed yeah and I think you’ve done some research in the work comp workers compensation space as well looking at the outcomes of people yeah who have who’ve had a lumber fusion if you’ve had a workers compensation injury yeah a lot of my early research and actually my my uh part of my phd thesis was on I was fascinated by this 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 realize that these are very different people um and often there’s lots of um psychosocial problems that are 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 it’s a very very bad system that’s rife with perverse incentives and it’s there’s perverse incentives for the surgeons as well because the payments that we receive from the workers compensation system uh 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 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 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 we did a meta-analysis on outcomes after different types of surgery so this was lumber fusion for instance but also carpal tunnel syndrome um a bunch of other comments 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 um so you know three to four times the odds of um of a bad outcome it’s you’re really setting yourself up to failure when you operate on this people and yet it’s it’s commonly done we’re just trying to publish some stuff on that now we just looked at all the sierra data so in new south wales the workers comp uh system now is managed under sera which is the state insurance regulatory agency um 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 and we looked at whether they had how they were 24 months after the surgery the probability of returning to pre-injury duties after two years after spine fusion was three percent 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 um and so that’s kind of shocking isn’t it workers comp system yeah it’s almost shocking to hear statistics like that and and I suppose the question then is like you know you’ve got a you know 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 and but that’s a really hard message for someone who has pain to hear 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 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 I do not question in any way the fact that they 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 behavior 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 and they 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 and so you all I try to do in my role because I’m not a chronic pain specialist or a rehab person or anything like that is 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 yeah 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 uh contributing to their current unpleasant experience which is you know being expressed by back pain and and frustration and anxiety and all the other things that they’re feeling but just to get get them thinking that that may be a little bit more complicated than that and 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 that the 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 and there are plenty of people with those exact science who don’t have any pain so it’s not again it’s not that simple thing humans love shortcuts you know where we’ve evolved to make these uh heuristic um uh conclusion jumps um 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 um uh patients can just stop thinking right there and just say okay take it out I’m done uh that’s you’ll cure me um so telling people that isn’t that simple is hard work and how what kind of response do you get because obviously they’re coming to you as a for a second opinion so um you know you’re you are 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 does that how does that how do people respond to that 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 I don’t know if it’s a good response or not but when people say um you know you’re telling me it’s all in your head I I tell them all pain is felt in the head that’s that’s where pain is registered um 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 um and 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 um you know a lot of people I think don’t really want to have surgery um and so they’re fairly relieved or happy to know that they don’t need to have surgery at least yeah 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 but some people are relieved um and particularly maybe it depends on who they’ve come from um 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 you know entirely reasonable you know intelligent good surgeons uh who care a lot about their patients and and and don’t take these things um willy-nilly but but there are surgeons out there that that are you know reasonably aggressive and and sometimes patients feel as if they’ve been pushed into surgery a little bit uh and they’re not sure that it’s really needed and uh um and sometimes they’re happy for and out you know even if it’s that that I 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 so how how do you get on with this messaging with your colleagues because you know clearly as you I don’t know what the numbers are for lumber fusions in australia but I imagine that pretty huge and particularly in the private and work comp space in my right compared to um the public setting yeah so we’ve recently 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 um for the 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 um are much more common in people over 60. yeah 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 it’s then then you do see that workers probably is a little high but 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 and found that the rates were increasing and very 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 their 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 why do you think that is that is that I I think that I would guess that 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 keep in terrible pain and can’t sleep and can’t walk around don’t get a hip replacement it doesn’t matter whether public or private uh because we know it’s an effective operation I think it’s different if someone comes into you with back pain and if someone comes into you with back pain and they’ve got you know degenerative changes or whatever and that fail 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 you know correlated with the findings on the scans there’s lots of complex reasons reasons why you have pain the best evidence we have you know that is that surgery will probably not help you that you know there isn’t really very good evidence uh supporting it at all um so I wouldn’t recommend we do such a a dangerous procedure for 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 we some people do better some people some people don’t uh you know we really don’t know you know there’s a lot of controversy out there about spine surgery um but we really won’t know you know whether you’re the right person for it whether you’ll respond to it and until we try it um and uh you failed everything else so I can’t really see you getting better without it um 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 different different bias and so what do you say then too and this kind of gets to the title of your book um 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 yeah how do you respond to that yeah well for every one of them I think there’s there’s a patient who says they regretted having the surgery but um yeah so that you’re getting to really the core of the book um which is this this problem that um

 

the 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 and 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 the 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 um you know and you’ll believe it um but it’s a true belief the other analogy I give is that um it’s like homeopaths homeopathic classic because homeopath homeopathy is is true nothing like that is blank treatment you know you’re giving water in small amounts so it’s 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 charlotte that 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 it 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 it’s 100 again it’s completely normal so 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 hasn’t shot a problem gets a scan shows it rotate a cuff tear which we know are really common and people with no pain at all that gives them a simple explanation to why they hurt they then believe they need to fix it yeah yeah so you just got to educate them I mean and and you just say um you know it depends on the condition but you guys probably know the figures more than me but but most people with shoulder pain will will be better in 12 months and I suppose the tricky thing there Ian is for the people we know in back pain which we know are around 25 percent who don’t get better from an episode of back pain and that that’s the really tough thing is because if we look at the five or seven year trajectories of that group they don’t tend for good yeah it’s not good but that’s what’s so tough about this whole conversation is like well if i’ve tried all the stuff and I haven’t got better then surely 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 and my pain and therefore this is my only option yeah it’s so compelling but that’s you’ve basically outlined the the argument of a lot of reasonable surgeons yeah they they would they would make that argument uh and it’s but it is largely based on their personal experience and and some not very good evidence um I think we need better evidence to find out if it works so instead of us all guessing yeah we should be doing the studies and this is another big frustration of mine is that we we think up these these things we 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 like isn’t that isn’t that drugs aren’t allowed to be put out of the market before you test them why is surgery yeah isn’t that just a basic principle of learning and science is to is to find out if things work first and then try them instead of what we did with the arthroscopy is we started doing it in the 70s and 80s and in 2013 we published a trial showing it doesn’t work like shouldn’t that trial have been done in 1980 I don’t know it’s hugely concerning though but because for consumers they put so much trust in the health system yeah and and we yeah but we abuse that trust um we know and you know if if the surgeon says you need this pretty hard to talk people out of it because it’s a very authoritative voice in society um that often you know doesn’t often get questioned and because it doesn’t often get questioned it I think it gets abused and yeah you can you can just say no no I 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 you know submit a document to the uh therapeutic goods association or the medical benefits schedule of australia to prove that it works um you know do you see that culture changing with young surgeons coming through yes yeah I definitely think that the young student is a different breed to to older surgeons uh for sure yeah so things are changing but I think the change really shouldn’t be generational in nature it should be a little faster than that um but I I’m aware that um you know I think one of the wiser initiatives suggested that um public funding shouldn’t be used but for um spine surgery and that got rolled because it was an outcry and and so funding’s been kind of reinstated 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 when um the mbs was was written on 1985 and that 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 um so my argument is that okay 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 and I would even argue that we need to use the public money for that so um 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 uh and then they can save themselves yeah millions of dollars a year so 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 and that’s consistent with the most recent guidelines for back pain is that um I think the nice guidelines said spinal surgery should only be used as part of a research trial yeah but we ignore the guidelines don’t

 

but uh we um it’s a it’s a very uh compelling case to say that um 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 if I’m going to have to subject it to all your testing 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 yeah 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 and 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 yeah it should work yeah so some of the listeners to this will be kind of shocked I would think um by what you’re saying uh but but the other thing that you highlighted this is a whole risk benefit thing and that that surgery is not without risk can you just talk through what kind of risk might be involved with something like a spinal fusion yeah so um 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 uh to hold things together and so the risks the the complications that it can occur after spine fusion surgery are higher than after um simple decompression surgery or or an arthroscopic surgery so for example a shoulder arthroscopy or knee arthroscopy it’s fairly safe surgery it’s it’s done day only the patient really doesn’t bleed at all they don’t need you know 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 you know well below one percent so they’re there but they’re very low but spine fusion surgery is a different story um you know if you you can have you’re very close to the nerve so you can have damage to to the nerves uh and sometimes some of the screws you put in cannot go in the direction they’re meant to go you can get bad bleeding um and probably the biggest complications of spine surgery is that it 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 um and so they take more stress and um that can cause problems um and often things come loose or they get infected or they’re sticking out a little bit or they’re rubbing um and all the fusion doesn’t take and it needs to be redone and so the revision operation uh percent is very high and that alone I think is is not a good sign so to give we we do have some recent numbers for that so if you look at um say hip or knee replacement as for me that’s like super common surgery everybody knows somebody’s had a hip or knee replacement the risk of needing another operation uh within within a year or two is pretty low um it’s 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 um but it’s you know it’s a couple of percent you need to take that into account um but once you get over that the 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 we did we found that the re-operation rate within two years uh 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 it’s that in itself tells you this is not a great operation yeah yeah and you know if you think about like the the fact that we actually have a name for it don’t we fail back syndrome yeah she’s kind of shocking but I don’t know if any other authentic procedures got that name has it no no no surgeons don’t like that name

 

so I’m very aware that there’s reasons they could way more of your time that this is such an interesting and important conversation um anything you guys want to kind of add because I feel like we probably have to wrap this up so yeah probably a question that i’d like to ask you yeah is what would you tell consumers that they should what conversation should they have with clinicians when it comes to surgery are the key questions they should be asking yeah that’s a very good question that I that I often I often get asked what I normally advise patients to do is uh to do exactly what I do when I am the patient or my parents or 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 that’s really boiling it down to nuts and bolts um 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 uh consultation and he like reacted oh what are you talking about you know just because we you know don’t have some so I i’ve got so you don’t know is the answer really didn’t know you know he’s just saying how safe it was in his hands and how his complication rate was low uh and that’s all great but I said but but what’s the probability of getting a good outcome with the surgery compared to not doing it it’s the most basic uh counterfactual way of thinking um 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 uh musculoskeletal pain and so it’s back fusion it’s it’s osteoarthritis it’s shoulder surgery it’s carpal tunnel it’s uh I think osteotomies uh ankle surgery or all the common the most common procedures we do for pain 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 um 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 so the evidence for what we do as surgeons for musculoskeletal pain is very bad I suppose I have one sort of final question then um 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 um what does the future hold for us you talked about some initiatives and some changes that you you’d make um what’s where are the wins going to come from in the future what’s the future for install for the future for you and what’s this landscape we’re going to look like yeah so we we need to change practice and changing practice is a whole special area of research almost um and and it’s I think it’s got to be multi-pronged so one of my uh things has been to teach surgeons so during surgeon training now um you have to learn more about evidence-based medicine and and things like that so 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 um 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 um external you know regulatory financial levers people are paying for this um and what’s what gets me is that I’m paying for it so I’m a little bit uh you know happy for doctors to do what they think is best you know um but what I say is that I don’t want to pay for it so if you want to go uh 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 buy beware in there um and 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 and I’m not going to pay for it I mean the government’s 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 I don’t want them to pay for it so I think there is a 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 compensation settings that they’re not getting value for money and they maybe need to rethink how they allocate money and should they be rewarding uh 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 yeah that’s great thank you so much for your generous time I did suggest 30 minutes I think we’ve almost doubled it probably could have gone for a couple hours but actually we’ve got to let you go we really really value this and I I know about our listeners will really value this conversation and um you know it takes a lot of guts I think to do what you’ve done in your career um it takes a a lot for a person to shift and you know we see people like gordon waddell and others um who have shifted across their career I think it’s a huge testament to you as a person and as a healthcare practitioner um that you’ve done that and we’re grateful for it so thanks so much and I hope you have a wonderful christmas thank you thanks everyone 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 chiropractors and so on that perform treatment that doesn’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 in talks about commonly it’s natural history or it may be other phenomena contextual effects like regression to the mean a feeling of being listened to looked after cared for having a condition made sense of or a feeling of safety okay 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 jillian o’shaughnessy from ABC back in 2018 and then i’ll play the clip from abc730 program which talks about his journey and a huge thanks to ABC for granting us permission to use these clips for educational purposes uh stephen is in padbury steven is 24 and he’s had a spinal fusion hi stephen hello how are you yeah well thank you that’s good um yeah like you said I was actually told the wrong age I’m 26 and i’ve had a problem since I was 21 with um chronic pain I obtained an injury at work um i’ve had two two um decompressions of the uh the discs at l45 um and then last year I received a single level spinal fusion yeah um I’m just i’ve been to a lot of different sort of specialists and the main thing that i’ve told me is what you’ve been saying is going to the cool and you know just keep keep moving but the pain is just really really immense my body gets really tired really quickly um I find that I sleep quite quite a lot um if I’m not moving a lot um 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 um 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 um my ques my questions about the medication um I’m actually on uh I’m not on any opioids um am I allowed to say the the type of drug I’m on yeah yeah go ahead okay so I’m on um uh north pan I’m on um alexia tramadol um celebrities uh and an antidepressant of pristine um do you think that these drugs will do any benefit for me um with with my chronic pain 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 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 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

 

that whole time that I did have back pain I was looking for that quick fix Steve dural is back at hockey training after a tough few years he hurt his back working on a building site my back was seizing up and it was quite scary I wouldn’t be able to walk without my leg dragging behind me

 

in the end Steve had three operations the final one a spinal fusion I’m feeling no relief from these operations

 

Steve dural says a six-month physiotherapy program achieved what surgery couldn’t treating his back pain and helping him return to sport and work if I had my time again and doing this whole process I would definitely explore other options and getting surgery to start off with 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 podcast at bodylogic.physio 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 theme music generously provided by ferven and cash