Haroon M Pillay MCh, DNB, FRCS Ed,
FRCS (S/N)
Normah Medical Specialist Centre, Kuching, Malaysia
Address for Correspondence: Dr. Haroon M Pillay MCh,
DNB, FRCS Ed, FRCS (S/N), Normah Medical Specialist Centre,
Kuching, Malaysia. E-mail: haroonmpillay@gmail.com
Keywords: history taking, history
Having practiced spinal surgery, having seen tears and
laughter from many of my own patients and from others'
experience, I would like to add on to a genuine concern Prof.
NJ Mani expressed in his editorial "Whither to?" [1].
We all know that these days, many spinal surgeries are done
for back pain or sometimes spinal fusions are done following
spinal canal decompression. We also know that back pain is
very common in the general population. We also are aware that
the common causes of back pain are anxiety, stress, worry,
depression, muscle spasm, flabby muscles, bad posture,
referred pain from sacroiliac joint pain, piriformis syndrome,
retro peritoneal pathologies, facet joints etc. In
addition we all know that MRI is done at the drop of a hat for
patients with back pain. We also know that MRI most often
shows disc bulges, ligamentum flavum hypertrophy, facet
hypertrophy and canal compromise. We also know that
these findings are common in many asymptomatic people and are
part of a normal aging process. We all seem to know
everything, aware of everything and are knowledgeable about
everything. But what we don't know or fail to know is that
when we face a patient with back pain in our clinic, we forget
all that we know! We tend to get influenced by the MRI
findings or report and totally ignore a significant part of
clinical evaluation. And that significant part is History
taking. In no other aspect of medicine does history play such
an unequivocal role in decision making as in spine surgery.
But this is where most of us stumble, and we see history as a
thing of the past. Why bother to waste time on history when we
have all the modern gadgets for investigation and treatment at
our disposal?
Many spine surgeons, especially the younger ones and new
entrants into this exciting specialty get carried away by the
advances in technology such as endoscopes, fixation devices,
bone substitutes, fusion enhancers etc. They also get
mesmerized by the beautiful post-operative images showing
multiple screws, rods and hooks perfectly aligned in the spine
- from the front, back and sides. Sometimes it makes me
wonder whether the English phrase "screwed up" has been made
after witnessing the umpteen numbers of such spinal fixations!
It is common knowledge that 80% of the decision to perform a
spinal surgery comes from a detailed history - history of the
patient's symptoms, his personality, his life style, his
family and social background, his job description, his
expectations of the outcome of surgery etc. but the moment we
see an "abnormality" in a spine MRI, we throw common sense
into thin air and rush to sharpen our scalpels, polish our
endoscopes and unpack our fixation devices with a sort of
vengeance unheard of even in the most brutal wars.
Notwithstanding the best interest of the surgeon to help the
patient, the final result is most often an excellent looking
post-operative X-ray and a miserable looking patient. Spinal
surgery has become more of a cosmetic surgery with the main
aim to enhance the beauty of an ugly looking spine in an MRI
scan to that of a presentable spine. And how do we do it? We
do it by decorating the spine with all the latest screws,
rods, nuts and bolts. And we all say Bravo to this dressed up
spine which reminds one of the shiny armors the ancient Roman
soldiers decorate themselves with to show off their supremacy
and success.
I would like to emphasize that I don't intent to undermine the
utility or effectiveness of spinal surgery. In fact I believe
in the relevance for spinal decompression or/ and fixation.
Yes spinal surgery is here to stay - but with the correct
indications. All that I am trying to emphasize is that the
mere possession of an endoscope or implants and an ugly
looking MRI or even our own supreme technical expertise should
not be an indication for spine surgery. In other words we
should refrain from proving the relevant age old adage "
A
man equipped only with a hammer will find everything else as
a nail head". Focus on the basics. We are treating a
patient, not an MRI. Technological advances and expertise is
NOT a substitute for a detailed history in decision making in
spinal surgery.
I dedicate this editorial to Prof: N.J.Mani - a most
respectable professional, who has spent his life in total
commitment to patient care and education. I would like to end
my views by emulating the question Prof: NJ Mani asked:
Spinal Surgery - Quo Vadis?
Reference
1. NJ Mani. Whither to? BMH Medical Journal 2016;3(4):83-84.