Dr. Mark Nelson - 2nd visit

I met with Mark Nelson again over at Oasis. He has got to be one of the nicest doctors I've met. First off, I thanked him for writing a letter on my behalf which said I'd be a good candidate for disc replacement and which could help my insurance appeal. Then I updated him on my current situation and asked him to review my latest (Jun. '08) MRI and discuss options, including fusion (in case my appeal is denied).

We looked at the MRI, and he zeroed in on the L5/S1 disc space saying it looked "painful" noting the wavy vertebral edge and contrast. He said the L4/L5 looked borderline. We discussed my (Dec. '07) discogram and, although he said it isn't the perfect test, all signs point to discogenic pain.

We then had a lengthy discussion of my options starting with managing my pain, avoiding activities which aggravate the back, and basically doing nothing. He said that was probably the best option and -- with an average pain level of only 2 or 3 -- probably what he would choose. He said it was possible, although perhaps unlikely, that the pain would just go away on its own.

We talked about disc replacement and the pros and cons of that procedure. He was very concerned about the anterior (front-side) surgical approach, especially if they had to modify or remove the discs later. Apparently the scar tissue formed by moving everything aside can be very problematic if a surgeon needs to go in a second time. It is very easy to tear something including one of the major blood vessels (e.g., femoral artery) which traverse the area. He also felt like the FDA study did not show that ADR was significantly better than fusion, and of course no one knows the long-term results. He is still very much on the fence about the efficacy of the procedure and doesn't do them himself.

We then got into fusion, and he seemed a bit reluctant to go there, considering my age and other factors. He said that he rarely does them for back pain by itself but more for relief of sciatic (leg nerve) pain. He said the success rate for fusion is around 50%, and many people do not achieve pain relief. In fact, he said that he would consider a successful fusion to be when a patient tells him nine months later that they have 50-60% pain relief. Furthermore, the recovery is brutal and, for at least a few months, the patient is typically in more pain than before the surgery. He mentioned that he has noticed quite a few surgeries at the hospital for removal of fusion hardware after it had been determined to have not helped the person. He thought it was better to leave the (inert) stuff in there rather than undergo a second surgery, but the point is that there are many cases where fusion simply doesn't relieve back pain, and the patient wants the metal out. I asked him about different materials such as the PEEK or composite rods. He felt like a fusion was a fusion, and the rod composition didn't really matter that much.

I then asked him about some newer alternative techniques I've been reading about such as endoscopic (laser) spine surgery (see laserspineinstitute). He was very skeptical about the laser saying most orthopedic surgeons didn't really see the practicality of the instrument. He compared the procedure to IDET where they burn the edge of the herniated disc -- which likely wouldn't do me much good. He said some of these doctors and medical groups have very good marketing departments, but he told me not to be fooled by these newer procedures which were unlikely to be any better than existing techniques ("nothing new under the sun").

He mentioned that the medical system is set up to encourage surgery. The device manufacturers are interested in selling their products (e.g., artificial discs, fusion rods, etc.) while doctors stand to make significantly more money from surgeries versus office visits. He gave an example of my visit today from which he might pocket $50; but if he did a surgery on me, then he might make $5000. So, is it any wonder that doctors recommend surgery? Sad but true. He was very forthright about my options and finally told me that if he was in my shoes, while understanding the psychological effects of enduring constant low-grade pain, he would still probably hold off on surgery. Things could conceivably get better on their own. Even if bone spurs and arthritis were to develop, it was still not out of the realm of possibility to be pain-free. Bottom line is that doctors still don't understand lower back pain very well, unfortunately.