When to operate and what to operate upon
Selby, D.K.
Orthopedic Clinics of North America 14(3): 577-588
1983
ISSN/ISBN: 0030-5898 PMID: 6866454 Document Number: 216398
It is apparent that the results of spinal surgery are less than optimal. The three major causes appear to be as follows: Patient selection. There are some patients who, owing to psychological change or secondary gain, are unable to respond to correction of a spinal problem. This is probably a very small percentage of the 25 to 35 per cent failure rate listed in the literature. Many of these patients have had the wrong operation for an unknown structural diagnosis. It is too tempting and easy for the spinal surgeon to blame poor results on the psyche. Structural diagnosis. It has been 40 years since Dandy published a report on "the hidden disc," but the world of spinal surgery still has not recovered from it. Poor Dandy is also credited with introduction of the method of shaking the spinous process as a test for instability and hence fusion. It would seem obvious that any disc surgery based on a premise of exploration for a hidden problem is antiquated in the day of the CT scan. One should be further chagrined by decision making for fusion based on shaking the spine with a towel clip. It would defy any spinal surgeon to define in rational terms how much observed motion is "abnormal." Until a structural diagnosis is made on the basis of clinical and laboratory testing, there is no indication for surgery. This is the single most important factor in spinal surgery. The success rate will not change until this function is universally recognized. Proper operation. There is little room, in modern spinal surgery, for the surgeon who is a "one trick pony." Uniform application of an operative technique to a variety of deforming forces will result in a high failure rate. It is the duty of the spinal surgeon to have all the techniques available and be able to apply them with precision and skill. Specific surgical response must be made to a specific structural diagnosis. The foregoing three principles should greatly enhance surgical results.